**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include:Based on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident #1) reviewed for wound care, the facility failed to ensure the record was complete and accurate to include a verbal treatment order and failed to include timely documentation of wound care provided. The findings include: Resident #1's diagnoses included panniculectomy (removal of excess fat/skin in lower abdomen) during 2024, infection following surgical procedure and wound dehiscence (reopened). Physician order dated 7/7/2025 directed to change wound vac dressing three (3) times per week on Monday, Wednesday and Friday. The Resident Care Plan (RCP) dated 7/7/2025 identified Resident #1 was at risk for skin breakdown and had a wound vac to the lower back related to a surgical wound dehiscence (reopened). Interventions directed to provide wound care as ordered and notify wound specialists as ordered/needed. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen out of fifteen (15/15), indicative of being cognitively intact, and had a surgical wound. Review of the MAR/TAR (medication administration/treatment administration record) dated 7/21/2025 identified RN #1 had documented wound treatment as hold/held and see nursing progress notes. A nursing note dated 7/21/2025 at 3:16 PM by RN #1 identified wound vac dressing change was on hold, and an alternate dressing was applied until wound vac machine is replaced. Order was placed and estimated to arrive today. Review of the physician orders failed to identify an order for an alternative dressing in replacement of the wound vac on 7/21/2025 through 7/23/2025. Interview and clinical record review with RN #1 on 8/25/2025 at 12:10 PM identified Resident #1's wound vac had stopped working on 7/21/2025 and RN #1 had notified the DON #2 to order a new wound vac. RN #1 stated he had notified APRN #1 regarding the issue and received a verbal order to place a wet to dry dressing until the new wound vac was delivered to the facility. RN #1 was unable to provide documentation that the verbal order was placed in the electronic medical record (EMR) but indicated he should have entered the order in the record. RN #1 stated he must have forgotten to document in the EMR. Interview with APRN #1 on 8/25/2025 at 12:25 PM identified RN #1 notified her that Resident #1's wound vac had stopped working. APRN #1 gave a verbal order for a wet to dry wound dressing (treatment) until the new wound vac was received, for Resident #1's wound and to follow-up with APRN #2 accordingly if there were any other changes noted. APRN #1 identified verbal orders should be placed in the EMR. Review of the facility undated Physician Orders Policy directed in part, written and/or verbal orders may be obtained. When taking verbal/telephone orders write down the complete order and read-back to verify. Verbal/telephone orders must have the abbreviation T.O. documented followed by the provider's name and credential and authorized person receiving the order (i.e., T.O. Dr. Brown/J. [NAME], RN). Review of the facility undated Nursing Documentation Policy directed in part, documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for one of three residents (Resident #6) reviewed for abuse, the facility failed to ensure the State Agency was notified timely of an allegation of abuse. The findings include: Resident #6 was admitted with diagnoses that included borderline personality, post-traumatic stress disorder. A resident care plan (RCP) dated 7/25/2024 identified Resident #6 exhibited accusatory behaviors and poor impulse control towards staff's care. Interventions directed to approach in a clam manner, explain all procedures and medications before administering and do not engage if resident escalates or becomes accusatory. A quarterly MDS assessment dated [DATE] identified Resident #6 had a BIMS of 15 meaning he/she was alert and oriented, and was independent with ALDs and mobility. A facility grievance form dated 8/25/2024 identified Resident #6 reported that the weekend supervisor had recorded her/him on his cell phone saying Resident #6 had psychological problems. Interview and review of the grievance with the DON on 10/28/2024 at 11:30 AM identified that she had reviewed and investigated the grievance reported by Resident #6 on 8/25/2026. The DON stated she did not consider the grievance to be an allegation of abuse and she did not report that allegation to the State Agency. Subsequent to inquiry, the facility submitted the allegation to the State Agency. The facility policy Protecting Resident Privacy and Prohibiting Mental Abuse directed in part, each resident had the right to be free from all types of abuse included mental abuse. The Policy further indicated, related to photos and audio/video recordings by staff, that the facility defined mental abuse to include abuse that is facilitated or caused by nursing home staff taking or using recordings in any manner to demean a resident. The facility policy Abuse/Resident in part, directed that upon reports of an allegation of abuse or mistreatment, the DON, Administrator or designed will immediately conduct an investigation and submit a notification to the state survey agency within two (2) hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for grievances, the facility failed to ensure interventions were put into place timely to prevent a wandering resident from entering another resident room. The findings include: Resident #1 had a diagnosis of dementia. The admission Minimum Data Set (MDS) dated [DATE] identified Resident #1 had moderate cognitive impairment and used a wheelchair. The Resident Care Plan (RCP) dated 2/29/2024 identified Resident #1 had wandering behaviors. Interventions directed to redirect and engage in activities. Record review identified Resident #1 was self-mobile in a wheelchair. Resident #2's diagnoses included panic disorder, anxiety, and post-traumatic stress disorder (PTSD). The quarterly MDS assessment dated [DATE] identified Resident #2 as alert and oriented and was independent with ADL care. The RCP dated 2/17/2024 identified PTSD, anxiety, and panic disorder. Interventions directed to provide emotional support, give adequate time to process requests and respect residents right to refuse. Clinical record review identified Resident #2 had a designated emergency contact person. Review of facility grievance dated 3/5/2024 identified Resident #2 alleged another resident entered his/her room over the past few days and a prior occasion the same resident had blocked his/her access to the room doorway. Resident #2 reported he/she felt unsafe, was offered a room change, and Resident #2 declined the room change. The grievance further identified although the 11 PM to 7 AM staff attempted to redirect the resident from Resident #2's room, he/she had to wait for staff to respond to her request. The grievance identified a new plan was to apply a stop sign to the doorway, and was applied on 3/5/2024. A social worker's note dated 3/5/2024 at 8:51 AM identified SW #1 spoke with Resident #2's emergency contact person regarding another resident (Resident #1) entering Resident #2's room during the night on 3/2, 3/3 and 3/4/2024. The note identified Resident #2 awoke to Resident #1 sitting on his/her bed, and on another occasion Resident #1 tried to block Resident #2 from using the door. A social worker's note dated 3/5/2024 at 12:29 PM identified SW #1 met with Resident #2 to discuss his/her concerns regarding a resident wandering in his/her room for the past three (3) evenings. SW #1 discussed room change options were semi-private rooms, Resident #2 chose to remain in current room, and indicated to SW #1 that the 11 PM to 7 AM aides redirect the other resident, but it takes time for staff to remove the other resident because the aides are caring for other residents. Review of nursing notes from 2/29 to 3/5/2024 failed to identify Resident #1 entered Resident #2's room. Interview with Administrator on 3/28/2024 at 12:08 PM indicated that Resident #1 wandered into Resident #2's room twice, that Resident #2 declined moving to another room on the opposite side of the building. The Administrator stated Resident #1 was moved closer to nurse's station for more frequent monitoring due to Resident #1's concerns, and a stop sign was placed on Resident #2's door on 3/5/2024. Interview with the Administrator and SW #1 on 3/28/2024 at 1:18 PM identified although nursing staff were aware Resident #1 had wandered into Resident #2's room and removed had removed Resident #1 from the room on 3/2, 3/3 and 3/4/2024, the Administrator was unable to provide documentation that interventions were put into place to prevent wandering into Resident #2's room until 3/5/2024 (three days after the first incident). Although attempted, an interview with DNS #1, RN #1, RN #2, RN #3, NA#3 were not obtained during survey. The facility did not provide a policy for surveyor review regarding timely interventions for wandering residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 302 was admitted to the facility on [DATE] with diagnoses which included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. A physician's order dated 2/16/24 directed to administer Lagevrio (an antiviral medication for Covid 19) 800 mg twice daily for 5 days. The care plan dated 2/19/24 identified Resident #302 required staff assistance with activities of daily living (ADLs). Interventions included assisting with mouth/dental care. The care plan also identified Resident #302 was admitted with Covid 19. Interventions included to assist in meeting all ADLs needs as needed. Observation and interview with Resident #302 on 2/25/24 at 7:54 AM identified that he/she had several issues with the facility addressing his/her personal hygiene needs. Resident #302 identified that he/she had not been able to brush his/her teeth from admission to the facility on 2/16/24 until 2/21/24, 5 days after admission to the facility. Resident #302 identified that he/she required set up and some assistance with dental care due to muscle spasticity in both arms. Resident #302 identified that he/she was only provided the ability to brush his/her teeth after a family member called the facility upset regarding not being provided a toothbrush. Resident #302 also identified that he/she had not had a shower since admission. Resident #302 identified the facility staff would provide assistance with a bed bath but Resident #302 did not feel clean and wanted a shower. Resident #302 identfied he/she hadnt been offered a shower due to his/her having Covid. Resident #302 identified that he/she had been cleared from Covid precautions on 2/22/24. During this interview, Resident #302 was observed with dried white flaky debris throughout his/her face, throughout the exterior visible areas of the ears, and scalp. Resident #302's hair also appeared to have several large flakes of dried white debris within his/her hair, and the hair itself appeared to have a large amount of grease or oil. Resident #302 identified he/she had asked to have a shower since admission and that all requests were ignored by facility staff, including the DNS. Resident #302 identified that he/she had felt ignored and I don't feel like I am being treated like a human being. It's a basic human right to be able to wash myself and brush my teeth. It's that right. Review of the unit shower list for 2/25/23 for Resident #302's unit identified that Resident #302 was to receive showers every Tuesday on the 7:00 AM-3:00 PM shift. Review of the resident care card from 2/25/24 for Resident #302 identified Resident #302 required assistance with bathing, preferred showers, and was scheduled for showers every Tuesday on the 7:00 AM-3:00 PM shift. Review of the nurse aide task documentation identified that Resident #302 did not have any dental care completed from 2/16-2/21/24. Further review of the nurse aide task documentation from admission to the facility on 2/16/24 through 2/25/24 at 10:00 AM failed to identify Resident #302 was provided any showers during his/her admission at the facility, a total of 10 days. Interview with LPN #4 on 2/25/25 at 10:30 AM identified that she was not aware Resident #302 had not had a shower since admission to the facility. LPN #4 identified she would make sure Residnet #302 reeived a shower today. Subsequent to surveyor inquiry, Resident #302 received a shower on 2/25/24 during the 7:00 AM-3:00 PM shift. Interview with the DNS on 2/26/24 at 8:59 AM identified she was aware Resident #302 had an issue with getting his/her teeth brushed but was not aware that Resident #302 had not received a shower. The DNS identified Resident #302 was upset about not being provided a toothbrush, toothpaste, or being assisted with teeth brushing from admission, and identified she was notified of the issue by a family member of Resident #302 the afternoon of 2/21/24. The DNS identified she was unsure why Resident #302 was not assisted with dental care, and also identified that while Resident #302 was admitted to the facility due to a positive Covid 10 diagnosis, this would not prevent him/her from being able to brush his/her teeth or being able to shower. The DNS identified that the facility would have scheduled Resident #302's shower at the end of the showers for the day, after all other residents had showered, and this was the policy for all facility residents on any precautions so Resident #302 should have received a shower on Tuesday 2/20/24, his/her first scheduled shower day. The facility policy on Residents' Rights directed residents of the facility had the right to be treated with consideration, respect and full recognition of their dignity and individuality. The policy also directed that residents had the right to receive quality care and services with reasonable accommodation of the resident's individual needs and preferences. The policy also directed that residents of the facility had the right to make choices about the aspects of their life that were significant to them. Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #18 and #302) reviewed for dignity, the facility failed to ensure resident was treated in a dignified manner and to ensure that the resident's rights related to personal hygiene were honored. The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included dementia, urinary tract infections, right femur fracture and falls. A physician's order dated 1/30/24 directed to administer Lasix 20 mg every morning. The admission MDS assessment dated [DATE] identified Resident #18 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required total assistance with dressing, toileting, and personal hygiene. Additionally, had no behavior. The February 2024 care plan identified Resident #18 needs assistance for activities of daily living. Interventions included assisting as needed to meet toileting needs and incontinent care per facility policy. Observations on 2/25/24 at 8:05 AM identified Resident #18 yelling from the resident's room into the hallway I have to go to the bathroom repeatedly. RN #1 was passing the room and from the doorway yelled over to Resident #18 lying in bed by the window you can pee in your diaper, you can pee in the diaper in there, we will clean you up later. Resident #18 indicated he/she wanted to use the bathroom. RN #1 left the entranceway of Resident #18's room and headed down the hallway to her medication cart. Resident #18 continued yelling he/she had to go to the bathroom. At 8:20 AM NA #2 brought in breakfast tray and left room instructing resident he/she had a diaper on and to use it. NA #2 did not provide any care or use of bathroom at this time. Resident #18 indicated he/she needed to use the bathroom and NA #2 instructed Resident #18 to eat breakfast and she would return . At 9:00 AM Resident #18 continues yelling out he/she needs to go to the bathroom. At 10:19 AM Resident #18 was still yelling I have to go to the bathroom, RN #6 was standing outside of Resident #18's room and informed RN #2 down the hallway at the medication cart that Resident #18 needed to use the bathroom. RN #2 from the other end of the hallway replied, Resident #18 has a diaper on. RN #6 indicated that someone needs to come assist Resident #18 now. At 10:31 AM Resident #18 continues yelling I have to go to the bathroom, help, help, help. At 10:32 AM RN #2 entered Resident #18's room and instructed Resident #18 to hold on and RN #2 left room. At 10:34 AM Resident #18 yelling I need help. At 10:40 AM NA #8 entered the room. Interview with NA #8 on 2/25/24 at 10:42 AM indicated that Resident #18 had a broken leg and could not get out of bed since admission yet, per therapy. NA #8 indicated she had just placed Resident #18 on a bedpan. Interview with NA #2 on 2/25/24 at 10:43 AM indicated she was assigned to care for Resident #18 today. NA #2 indicated she works full time and has Resident #18 every day she works. NA #2 indicated that she has not checked for incontinence, provided any incontinent care or morning care for Resident #18 because she had a heavy assignment on this side of the hallway, and they were short staffed. NA #2 indicated she had 9 or 10 total care residents to take care of this morning. NA #2 indicated this was the first chance she had time to come check on Resident #18 because she was with other residents. NA #2 indicated that RN #1 about 5 minutes ago told her that Resident #18 had a bowel movement and needed care. NA #2 indicated this was the first time today since she came in at 7:00 AM she has had a chance to take care of Resident #18. ( 3 hours and 45 minutes after the start of her shift) Observation of incontinent care on 2/25/24 at 10:55 AM noted Resident #18 was lying in bed on top of a soaker pad with a disposable blue pad on top of it. Resident #18 had on a disposable yellow/tan brief with a thick purple liner inside the brief. NA #2 removed the inner liner, the disposable brief, the disposable pad, and the soaker pad. Resident #18 had a large bowel movement in the bedpan. NA #2 indicated the purple liner was soaked and the yellow/tan brief was wet from urine. NA #2 provided incontinent care and applied cream. NA #2 indicated that Resident #18's peri area and buttocks were red so she was applying cream. Surveyor observation identified Resident #18's buttocks, coccyx and peri area were red and excoriated. NA #2 then placed a yellow/tan brief and added the purple liner inside the brief, applied a blue disposable pad and a cloth soaker pad underneath resident. Interview with NA #2 on 2/25/24 at 11:15 AM indicated that she double briefs Resident #18 because she thought it would absorb more urine and help prevent urinary tract infection. NA #2 indicated she had not been educated on why she should not double brief residents. Interview with the DNS on 2/25/24 at 1:55 PM indicated Resident #18 was incontinent and incontinent care was to be provided every 2 hours. The DNS indicated the residents should only be wearing 1 brief and there was not to be a liner inside of the briefs. The DNS indicated that Resident #18 had dementia but should not be instructed to urinate or have a bowel movement in a brief. The DNS indicated that it was a dignity issue. The DNS indicated if Resident #18 was requesting to use the bathroom the nursing staff should have placed him/her on the bedpan right away and not instructed resident to urinate or have a bowel movement in the brief. Interview with Infection Control Nurse (LPN #1) on 2/25/24 at 2:05 PM indicated that Resident #18 should not have double briefed, and staff had been educated prior to not double brief incontinent residents. LPN #1 indicated the nursing assistants should not double brief residents due to extra moisture that would cause the skin to breakdown. LPN #1 indicated Resident #18 should have been placed on the bedpan every 2 hours. LPN #1 indicated that residents should not be double briefed for dignity. LPN #1 indicated she would start the education on not telling residents to urinate in their briefs for dignity and not to double brief for skin care. Subsequent to surveyor inquiry, the care plan dated 2/25/24 identified Resident #18 may request to use the bathroom and can inform staff if needs to urinate or move his/her bowels at times. Resident #18 buttocks are red and continue with barrier cream. Interventions included checking and changing resident in the morning before breakfast and offer resident to use the bedpan. Additionally, Resident #18 wears a brief for dignity. Do not place a pad or another brief, one brief is appropriate and sufficient for his/her incontinence. Residents should not be instructed to eliminate in his/her brief. Resident #18 can use the bedpan. Review of facility Incontinent Care Policy identified was to promote cleanliness and comfort. Incontinent care is performed by nursing staff on all residents who are incontinent. Residents are checked every 2 hours for incontinence. Incontinent care is provided following episode of incontinence and as needed. Briefs applied per plan of care and changed with incontinent care. Review of the facility Brief guide identified the wetness indicator is designed to help staff identify when a resident has urinated and detects moisture inside the brief. Review of the facility Resident [NAME] of Rights policy identified the resident has the right to be treated with consideration, respect and full recognition of their dignity and individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident #35) reviewed for care planning, the facility failed to invite the resident/resident representative to participate in the care plan meetings. The findings include: Resident #35 was admitted to the facility in January 2023 with diagnoses which included transient ischemic attack (TIA), cerebral infarction, epilepsy, and dementia with psychotic disturbance. Review of the clinical record identified Resident #35 had an admission MDS dated [DATE], quarterly MDS dated [DATE], quarterly MDS dated [DATE], quarterly MDS dated [DATE], annual MDS dated [DATE], and a quarterly MDS dated [DATE]. The quarterly MDS assessment dated [DATE] identified Resident #35 had severely impaired cognition and required extensive assistance with bed mobility. Interview with Person #1 (Resident #35's representative) on 2/25/24 at 8:54 AM identified Resident #35 has been a resident at the facility since January 2023. Person #1 indicated he had never attended a care conference meeting in the last year. Person #1 indicated he had never received a phone call or letter from the facility inviting him to a care conference meeting regarding Resident #35 plan of care. Person #1 indicated this was the first time today he has ever heard of a quarterly care conference meeting regarding Resident #35 plan of care. Review of the clinical record failed to reflect that a care conference was held with the staff, resident, and/or resident representative at the time of assessments and/or care plan reviews. Interview with RN #3 on 2/26/24 at 1:18 PM identified she kept a sheet in her office recording resident care conference meetings. RN #3 indicated the workload has been a lot and they fell by the wayside. RN #3 indicated if the assessment part of the MDS is not completed it means unfortunately she missed the window due to the workload and not being able to complete the MDS assessments timely. RN #3 indicated the care conference meetings did not happen if it happened it would have been documented. Interview with the DNS on 2/27/24 at 7:00 AM identified she was not aware of the issue that resident or resident representative were not attending the care conference meetings on a quarterly basis. The DNS indicated it is the MDS coordinator's responsibility to schedule the meeting with the resident and resident representatives. The DNS indicated that the resident care conference meeting has gotten behind and RN #3 has been very busy. The DNS indicated that the MDS coordinator has been working per diem since 1/24 and the facility is in the process of interviewing for a full time MDS coordinator. Interview with the Administrator on 2/27/24 at 7:30 AM identified she was not aware of the issues in the MDS department. Interview with RN #3 on 2/27/24 at 8:58 AM identified she has been employed by the facility for approximately 6 years. RN #3 indicated she has been a part time MDS coordinator who worked 24 hours a week. RN #3 indicated as of 1/12/24 she has been working per diem approximately 16 hours a week. RN #3 indicated she is the only person in the MDS department and at times when she is behind in completing the MDS's corporate would send someone to help. RN #3 indicated it is correct that Resident #35 and the resident representative had not attended a care conference meeting for a year due to the workload becoming overwhelming. RN #3 indicated she has not been calling or sending invitations to the residents and the resident representatives regarding the care conference meetings. RN #3 indicated she does not document in the clinical record if a resident or resident representative attends a care conference meeting. RN #3 indicated she works remotely 8 hours and, come to the facility on Wednesdays for approximately 6 to 7 hours. RN #3 indicated she is aware residents must have a care conference meeting every quarterly (every 3 months) to review their plan of care. Additionally, RN #3 indicated she is aware that residents and resident representatives should be invited to the care conference meeting on a quarterly basis. Review of the facility care planning policy identified the purpose is to ensure residents have a comprehensive and individualized plan of care. A comprehensive and individualized plan of care will be developed for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of well being. A care conference to discuss the plan of care will be held on or before day 21 from admission and then at least quarterly. The resident and/or family/responsible party will be invited to attend all care plan conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #21) reviewed for choices, the facility failed to ensure resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. The findings include: Resident #21 was admitted to the facility with diagnoses that included cancer, chronic pain, diabetes, and sleep apnea. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition was not completed and required no assistance with dressing and personal hygiene. The care plan (not dated) identifies Resident #21 requiresassist as need with toileting needs and if he/she declines a shower provide a full bed bath and honor his/her wishes. The Resident Care Card dated 1/11/24 identified Resident #21 was scheduled for a shower on Thursdays on the 7:00 AM -3:00 PM shift and required total assistance. A physician's order dated 11/24/23 directed to give a shower weekly on Thursdays between 7:00 AM and 3:00 PM. Review of progress notes dated 1/1/24-2/25/24 did not reflect the resident had refused to have a shower. Interview with Resident #21 on 2/26/24 at 1:30 PM indicated since the beginning of last summer about June of 2023 he/she had been requesting only male nursing assistants for the showers. Resident #21 indicated he/she needed assistance to wash the peri area, back and buttocks. Resident #21 indicated he does not feel comfortable with a female touching the peri area due to the cancer. Resident #21 indicated he had informed all the nurses, Administrator, and DNS that he only wanted male nursing assistants for the showers and the last couple of months was requesting only male nursing assistants for morning and bedtime for care daily. Resident #21 indicated that he/she was scheduled for a day shower, but he/she wakes up for breakfast then due to the pain medications goes back to sleep until around 1:00 PM. Resident #21 indicated he/she had been asking to be changed to an evening shower and that would help to get a male nursing assistant. Resident #21 indicated there were 2 male nursing assistants on evening shift. Resident #21 indicated his/her shower day was Thursdays when there wasn't a male nursing assistant, and he/she was willing to change the day and shift to guarantee a male nursing assistant would be on to give him/her a shower. Resident #21 indicated he had gone 10 to 14 days without a shower for the last 6 months because when there was a male nursing assistant working they would be assigned to the other hallway and would not have time. Resident #21 indicated he had met with the Administrator and DNS, and they had informed him/her anytime there was a male on they would change the assignments so he/she would get the male nursing assistant. Resident #21 indicated that does not occur and Admianstration was aware. The nurse's note dated 2/26/24 at 10:58 PM identified around 8:30 PM Resident #21 approached writer requestion a male nursing assistant provide care instead of the female nursing assistant. This writer explained the male nursing assistant was busy trying to finish his assignment and the female nursing assistant would be providing the care shortly. Resident #21 became upset demanding male nursing assistants discarding the assignment. Informed resident that the female nursing assistant would bring in towels and gown and explained resident would clean him/herself and items would be brought in by female nursing assistant. Interview with RN #7 on 2/27/24 at 7:10 AM indicated that she worked a double from 3:00 PM on 2/26/24 until 7:00 AM today. RN #7 indicated Resident #21 had a female nursing assistant assigned to him/her on the 3:00 PM-11:00 PM but Resident #21 was upset and wanted the male NA. RN #7 indicated that she informed Resident #21 that the female aide had him/her this evening and the male aide was very busy and could not do him/her. RN#7 indicated Resident #21 was upset and prefers male aides if there is one working. RN #7 indicated the male aide was nice and didn't have to but did provide care to Resident #21 at the end of the shift once his finished his assignment. Interview with the DNS on 2/27/24 at 7:30 AM indicated she was aware since last June of 2023 that Resident #21 wanted male nursing assistants for showers but did not care for morning and bedtime care. The DNS indicated that about 6 months ago she had informed Resident #21 that there was not always a male nursing assistant working but if there was a male nursing assistant on the other side she would ask the male nursing assistant to go over to the other side to provide Resident #21 with a shower. The DNS indicated she was not aware that Resident #21 preferred a shower in the evening versus the day shift just that he/she wanted a male nursing assistant. The DNS indicated that Resident #21 last Friday 2/23/24 had approached the DNS and Administrator and informed them that he/she had not received a shower in the last 10 days and Resident #21 informed her they had the agreement about only males for showers since June 2023 and it was not happening. The DNS informed Resident #21 there was not a male nursing assistant working only females. The DNS indicated she thought Resident #21's shower was scheduled for 3:00 PM-11:00 PM but after clinical record review she noted it was scheduled for Thursdays 7:00 AM - 3:00PM. The DNS indicated she would make sure to switch Resident #21's shower from day shift to evening shift per resident's preference and there were no male nursing assistants on Thursdays so she would change the day. Interview with RN #1 on 2/27/24 at 8:30 AM indicated she was aware for at least the last 6 months that Resident #21 only wanted a male nursing assistant for showers. RN #1 indicated Resident #21 will refuse a shower with a female nursing assistant. RN #1 indicated she tries to accommodate Resident #21 with a male nursing assistant for showers by changing the assignments, but she can't always do that. RN #1 indicated sometimes the male nursing assistant will have a heavy assignment and won't have time to give Resident #21 a shower. Review of the facility Bathing and Shower Policy identified to provide proper personal hygiene, stimulate circulation, and promote skin integrity. Each resident will be offered a full bath or shower at least weekly. Assist resident out of bed to the shower room. Place resident under shower and do not leave alone. Review of the facility Resident [NAME] of Rights identified the resident had the right to be treated with consideration, respect, and full recognition of your dignity and individuality. The resident has the right to make choices about aspects of your life that are significant to you. The resident has the right to receive quality care and services with reasonable accommodation of your individual needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation, facility policy, and interviews for 2 of 2 sampled residents (Resident #36 and Resident #302) reviewed for advanced directives, the facility failed to ensure that advance directives were reviewed and obtained from the resident and/or resident representative. The findings include: 1. Resident #36 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrotomy, and diabetes. The admission MDS assessment dated [DATE] identified Resident #36 had intact cognition, was always incontinent of bowel and bladder, and was fully dependent on staff for toileting, dressing, and bathing. The care plan dated [DATE] identified Resident #36 required assistance with ADLs. Interventions included advance directives per physician's orders. Review of the clinical record failed to identify any documentation or physician's orders related to advance directives for Resident #36. Interview with Resident # 36 on [DATE] at 8:36 AM identified he/she did not have any discussion with the facility staff regarding his/her code status or advance directives. 2. Resident # 302 was admitted to the facility on [DATE] with diagnoses which included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. A physician's order dated [DATE] directed Resident #302's code status was CPR, indicating Resident #302 had a full code status. The care plan dated [DATE] identified Resident #302 required assistance with ADLs. Interventions included advance directives per physician's orders. Review of the clinical record failed to identify any documentation related to advance directives being reviewed with Resident #302. Interview with Resident #302 on [DATE] at 7:54 am identified that he/she did not sign or discuss anything regarding advance directive decisions with any facility staff members. Resident #302 identified The only paperwork they have given me to sign or fill out are surveys to fill out about my care. I haven't spoken with anyone about CPR. Interview with the DNS on [DATE] at 8:59 AM identified that all residents of the facility should have a signed advance directive form completed and located within the paper chart completed on admission to the facility by the admission nurse. The DNS identified that if a resident was unable to complete the form, the default code status would be a full code until the advance directives were reviewed and code status were obtained from the resident or resident representative. The DNS identified that Residents #36 and #302 should have had advance directives reviewed, signed, and documented within the clinical record and was unsure why the documentation was not completed. The facility policy on Advance Directives directed that the facility would provide the resident, or resident's representative, notice of the policy on advance directives and the resident's right to refuse treatment upon admission to the facility. The policy further directed that an informational sheet would be used to provide education related to the risks and benefits of full code and do not resuscitate. The policy also directed that if the resident or substitute decision maker did not execute an advance directive, the resident would be a full code until a decision was made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #202) reviewed for medications, the facility failed to update the physician and resident representative of refusal of medications and new orders for medications in a timely manner. The findings include: Resident #202 was admitted to the facility on [DATE] with diagnoses which included dementia, hypertension, cardiovascular disease, and diabetes. A physician's order dated 2/17/24 directed to administer Lispro insulin 3 units before meals, Olanzapine 2.5 mg twice a day, and Acetaminophen 975 mg three times a day. The nurse's note dated 2/17/24 at 5:04 AM identified Resident #202 was admitted to facility on 2/16/24 at 8:00 PM and was alert but confused and behavioral disturbances. The nurse's note dated 2/17/24 at 3:20 PM identified Resident #202 was alert with intermittent confusion. Resident #202 had increased agitation this afternoon and refused insulin and medications. Review of the MAR (medication Administration Record) dated 2/17/24 identified the 7:30 AM blood sugar was 144, the 11:30 AM blood sugar was 113, and the 4:30 PM blood sugar was 332. Additionally, the medications refused were Olanzapine( antipsychotic medication) 2.5 mg at 9:00 AM, Lispro insulin 3 units before meal at 11:30 AM, Acetaminophen 975 mg at 1:00 PM. Review of progress notes dated 2/17/24 - 2/19/24 did not reflect the physician and resident representative were updated of the refusals of insulin and medications. The care plan dated 2/19/24 identified cardiovascular disease and diabetes. Interventions included to administer medications as ordered by the physician. A physical order dated 2/19/24 for Olanzapine (Zyprexa for antipsychotic medication) 2.5 mg twice a day and 5mg every day as needed for agitation and reassessment in 14 days and Trazodone (sedative) 50 mg at bedtime and Trazodone 25mg every 6 hours as needed for agitation. The APRN note dated 2/19/24 at 1:59 PM indicated Resident #202 was a new admission and has had falls, anxiety, and restlessness. Plan to start Trazadone for anxiety and follow up with psychiatric provider and anxiolytic (Olanzapine/Zyprexa) medication as ordered. The nurse's note dated 2/19/2024 at 5:51 AM identified Resident #202 was sliding his/her feet out of bed twice. Olanzapine as needed was given for agitation with positive effect. Review of progress notes dated 2/19/24 - 2/23/24 did not reflect the resident representative was educated and informed of the new medication orders for Olanzapine and Trazadone. The nurse's note date 2/22/24 at 7:02 PM identified Resident alert and confused. Trazadone 25mg was given with effect. Blood sugar was 199 in the morning and 361 for afternoon and 268 for dinner. APRN made aware and new order obtained to increase the Lantus insulin 20 units to 24 units at bedtime. A physician's order dated 2/22/24 indicated to provide Lantus 24 units subcutaneously at bedtime. Review of the progress notes dated 2/22/24 -2/25/24 did not reflect the resident representative was informed of the new medication orders for insulin. Interview with the DNS on 2/26/24 at 12:10 PM indicated Resident #202 has a resident representative that must be updated when resident refuses medications, or if there are any changes to medications, or new orders for medications. The DNS indicated the physician or APRN must be updated of any refusals of medications and must be documented in the resident's progress notes. After review of the clinical record, the DNS indicated that the physician was not updated of the refusals of insulin and medications and there was no documentation that the resident's representative was updated of the new orders. Review of the facility Change in Resident Condition for Family and Physician Notification Policy identified all significant changes in a resident's condition will be reported to physician and resident representative. The nurse will document in the nurse's notes that the physician and resident representative have been notified of the change in condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure an allegation of verbal abuse was reported to the state agency, in a timely manner. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 identified Resident #39 had Parkinson's disease and was at risk for complications and injury related to muscle rigidity, dysphagia, fatigue, tremor, and as the disease progresses, he/she may also be at risk for memory and speech changes. Interventions included assisting Resident #39 to meet ADL needs and to be patient and encourage him/her one step at a time for activities because it may take longer to initiate voluntary movements. Interview with Resident #39 on 2/25/24 at 2:35 PM alleged NA #3 was rude, handled him/her strongly while providing care, and had directed specific expletive language towards him/her. During the interview, Resident #43 (Resident #39's roommate) identified, via dry erase board, that NA #3 had directed expletive language towards Resident #39. Interview with the regional nurse (RN #6) and the DNS on 2/25/24 at 3:45 PM identified that they were not aware of the allegation that NA #3 had used expletive language directed at Resident #39. The DNS indicated that she would immediately speak with Resident #39 regarding the allegation. A reportable event timestamped 2/26/24 at 8:30 AM identified the allegation of staff to resident verbal abuse, involving NA #3 and Resident #39, was reported to the state agency. Interview with the Administrator on 2/26/24 at 3:24 PM identified that prior to surveyor's notification of the alleged verbal abuse involving NA #3 and Resident #39 to the facility, she was unaware of the allegation. Interview with the DNS on 2/26/24 at 4:22 PM identified that the alleged incident had been reported to the state agency on the morning of 2/26/24; she did not report the allegation of abuse on 2/25/24 because during her interview with Resident #39, he/she would not directly answer questions confirming or denying the allegation that NA #3 used expletive language towards him/her. The DNS indicated that Resident #39 was more focused on discussing a customer service concern related to another nurse aide, which occurred the night before. The DNS further indicated that while she did realize that the allegation rose to the level of abuse, she had been focused on completing an investigation for a different resident and the untimely reporting was an error. The DNS indicated that the allegation should have been reported to the state agency and an investigation should have been started within 2 hours of learning of the event. The facility's abuse policy directs the Administrator/DNS or designee will immediately conduct an investigation upon submission of a report to FLIS( Facility Licensing and Investigation Section of the Department of Public Health) within 2 hours of notification of alleged allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure the abuse policy was followed regarding a staff member involved in an allegation of verbal abuse. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 identified Resident #39 had Parkinson's disease and was at risk for complications and injury related to muscle rigidity, dysphagia, fatigue, tremor, and as the disease progresses, he/she may also be at risk for memory and speech changes. Interventions included assisting Resident #39 to meet ADL needs and to be patient and encourage him/her one step at a time for activities because it may take longer to initiate voluntary movements. Interview with Resident #39 on 2/25/24 at 2:35 PM alleged NA #3 was rude, handled him/her strongly while providing care, and had directed specific expletive language towards him/her. During the interview, Resident #43 (Resident #39's roommate) identified, via dry erase board, that NA #3 had directed expletive language towards Resident #39. Interview with the regional nurse (RN #6) and the DNS on 2/25/24 at 3:45 PM identified that they were not aware of the allegation that NA #3 had used expletive language directed at Resident #39. The DNS indicated that she would speak with Resident #39 regarding the allegation. Review of NA #3's individual employee timecard dated 2/25/24 identified that NA #3 worked from 2:55 PM through 11:08 PM. A reportable event timestamped 2/26/24 at 8:30 AM identified the allegation of staff to resident verbal abuse, involving NA #3 and Resident #39, was reported to the state agency. Interview with the DNS on 2/26/24 at 4:22 PM identified that she did not report the allegation of abuse or suspend NA #3 in a timely manner because during her interview with Resident #39, he/she would not directly answer questions confirming or denying the allegation that NA #3 used expletive language towards him/her, as Resident #39 was more focused on discussing a customer service concern related to another nurse aide, which occurred the night before. The DNS further identified that she had also been focused on completing an investigation for a different resident. The DNS indicated that the alleged incident had been reported to the state agency earlier that morning and that NA #3 had been removed from the schedule and would remain off the schedule until the completion of the investigation. Interview with the DNS on 2/27/24 at 9:21 AM identified that NA #3 had not been immediately taken off the schedule following the notification of the allegation of verbal abuse on 2/25/24, and that NA #3 had worked the 3-11 PM shift on 2/25/24. The DNS indicated that NA #3 should have immediately been removed from the schedule, pending the investigation, and that it was an error that she was not immediately removed from the schedule. The facility's abuse policy directs the individual(s) accused will be immediately suspended without pay, pending the findings of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for the only sampled resident (Resident #39) reviewed for dignity, the facility failed to ensure the quarterly MDS and quarterly social work assessment were comprehensively completed. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The social services assessment dated [DATE] was incomplete. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed. The care plan dated 1/16/24 identified Resident #39 was taking opioid medication to help manage moderate to severe chronic pain. Interventions included monitoring for and reporting adverse effects including seizures, anxiety, agitation, hallucinations, and depression to the physician. The care plan further identified Resident #39 was at risk for potential adverse effects due to psychotropic medication use. Interventions included monitoring for and reporting unpleasant side effects including fatigue, agitation, irritability, and anxiety to the physician. Interview and clinical record review with SW #1 on 2/26/24 at 11:25 AM identified that she did not complete the cognition and mood sections of Resident #39's quarterly MDS dated [DATE]; it had been signed by the MDS coordinator. Interview and clinical record review with the MDS Coordinator (RN #3) on 2/26/24 at 1:08 PM identified that the mood and cognition sections of the quarterly MDS dated [DATE] were not assessed. RN #3 indicated that due to the volume of her workload she was not able to complete all sections of resident assessments, in a timely manner. Interview and clinical record review with SW #1 on 2/27/24 at 10:52 AM identified that Resident #39's social service assessment dated [DATE] was not completed. SW #1 indicated that the encounter in the electronic health record was initiated by another staff member whom she was not familiar with, and she did not know why the social service assessment was incomplete. Interview and clinical record review with the DNS on 2/27/24 at 6:58 AM identified that the mood and cognition sections of the 1/3/24 quarterly MDS were incomplete, but she would have to confirm with the MDS coordinator why the respective sections were not completed. The DNS further identified that she would expect the MDS to be completed on admission, quarterly, and with a significant change in condition. The facility's MDS policy directs the MDS to be completed according to the procedures and directives outlined in the MDS RAI manual. The MDS assessments will be completed by facility staff trained in the MDS process. MDS assessments will be submitted to the QIES database by an automated MDS submission process through PointClickCare within 14 days of the completion date of the MDS. Although requested a policy for social services assessments was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 6 residents (Resident # 20, #36) reviewed for comprehensive care planning, the facility failed to failed to develop and implement a comprehensive care plan. The findings include: 1. Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and diabetes type 2. The admission MDS assessement dated 2/3/24 identified Resident #20 had intact cognition, spinal stenosis- lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 had 2 care plans, one from dietary with a focus on obesity, not following diet at home with an intervention that included a controlled carbohydrate diet, and the second from the Activities Director with a focus on orientating to the facility with interventions that included one to one visits and calendar activities. An interview with the DNS on 2/27/24 at 10:00AM noted it is her expectation that comprehensive care plans are established per policy. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrotomy, and diabetes. Review of the hospital discharge documentation identified Resident #36 hospitalized from [DATE]-[DATE] and required multiple open abdominal surgeries, tracheostomy placement and decannulation, and gastrostomy tube placement during the hospitalization. The hospital discharge documentation also identified Resident #36 required tube feedings and insulin daily. The physician's orders dated 1/18/24 directed Resident #36 required Jevity 1.5 Kcal (a tube feeding supplement) at 75 cc/hr from at 6 PM to 6 AM; Jardiance (an oral diabetic medication) 10 mg once daily; Lantus (a long acting insulin for diabetes) 12 units twice daily; and a regular diet with level 3 texture and thin liquid consistency. Review of the clinical record identified a blank form labeled Baseline Care Plan within Resident #36's paper chart. A care plan dated 1/19/24 identified Resident #36 had a prolonged hospital stay with multiple medical conditions, weight loss, and tube feedings. Interventions included following weights, labs, and providing diet as ordered. The 1/19/24 care plan also identified Resident #36 required tube feedings. Interventions identified to provided tubs feeding and diet as ordered. The care plans dated 1/19/24 were documented as entered by the Dietician. Review of the clinical record failed to identify any documentation related to any additional care plans or interventions documented for Resident #36 on or after 1/19/24. The admission MDS assessment dated [DATE] identified Resident #36 had intact cognition, was always incontinent of bowel and bladder, and was fully dependent on staff for toileting, dressing, and bathing. Interview and clinical record review with RN #3 (MDS coordinator) on 2/26/24 at 3:05 PM identified she was the staff member responsible for ensuring a comprehensive care plan into Resident #36's clinical record. RN #3 identified she entered the admission MDS and comprehensive care plan into the clinical record at the same time. Upon review of Resident #36's clinical record, RN #3 identified I completely missed it. It's not there. RN #3 identified the comprehensive care plan for Resident #36 should have been entered on 1/21/24, with the admission MDS. RN #3 identified that there had been issues with staffing and the workload in the MDS department which resulted in things getting pushed to the side. Subsequent to surveyor inquiry, RN #3 entered comprehensive care plan documentation into Resident #36's clinical record on 2/26/24. Interview with the DNS on 2/27/24 at 8:45 AM identified she was not aware Resident #36 did not have a comprehensive care plan in place but it should have been entered by RN #3 along with the admission MDS on 1/21/24. The DNS identified that care plans being initiated and entered into the clinical record had been an ongoing issue at the facility and she had provided in-services to the staff over the past year, after she began in the DNS role. The facility policy for comprehensive care planning identified that the facility must establish a comprehensive care plan for each resident. The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing. The comprehensive care plan will be comprehensive and individualized plan of care would be developed for each resident. The policy further directed that a comprehensive care plan, based on the resident's identified needs, strengths, and preferences, would be developed no later than 7 days after the completion of the admission MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #18 and #302) reviewed for activities of daily living, the facility failed to ensure resident was provided the incontinent care timely and utilize briefs per standard of practice for (Resident #18) and the facility failed to ensure showers and personal hygeine needs were addressed for a newly admitted resident for (Resident #302). The findings include: 1. Resident #18 was admitted to the facility with diagnoses that included dementia, urinary tract infections, right femur fracture and falls. admission assessment dated [DATE] at 7:25 PM identified there were no marks or open areas to the coccyx, buttocks, and peri areas. A physician's order dated 1/30/24 directed to give Lasix 20 mg every morning. The care plan dated 2/1/24 identified Resident #18 needs assistance for activities of daily living. Interventions included assisting as needed to meet toileting needs and incontinent care per facility policy. The admission MDS dated [DATE] identified Resident #18 had severely impaired cognition, was frequently incontinent of bladder and always incontinent of bowel and required total assistance with dressing, toileting, and personal hygiene. Additionally, had no behavior. Weekly body audit dated 2/20/24 did not identify any redness to the coccyx, buttocks, or groin areas. Observations on 2/25/24 at 8:05 AM heard Resident #18 yelling from the resident's room into the hallway I have to go to the bathroom repeatedly. RN #1 was passing the room and from the doorway yelled over to Resident #18 lying in bed by the window you can pee in your diaper, you can pee in the diaper in there, we will clean you up later. Resident #18 indicated he/she wanted to use the bathroom. RN #1 left the entranceway of Resident #18's room and headed down the hallway to her medication cart. Resident #18 continued yelling he/she had to go to the bathroom. At 8:20 AM NA #2 brought in breakfast tray and left room instructing resident he/she had a diaper on and to use it. NA #2 did not provide any care or use of bathroom at this time. Resident #18 indicated he/she needed to use the bathroom and NA #2 instructed Resident #18 to eat breakfast and she would return after. At 9:00 AM Resident #18 continues yelling out he/she needs to go to the bathroom. At 10:19 AM Resident #18 was still yelling I have to go to the bathroom, RN #6 was standing outside of Resident #18's room and informed RN #2 down the hallway at the medication cart that Resident #18 needed to use the bathroom. RN #2 from the other end of the hallway replied, Resident #18 has a diaper on. RN #6 indicated that someone needs to come assist Resident #18 now. At 10:31 AM Resident #18 continues yelling I have to go to the bathroom, help, help, help. At 10:32 AM RN #2 entered Resident #18's room and instructed Resident #18 to hold on and RN #2 left room. At 10:34 AM Resident #18 yelling I need help. At 10:40 AM NA #8 entered the room. Interview with NA #8 on 2/25/24 at 10:42 AM indicated that Resident #18 had a broken leg and could not get out of bed since admission yet, per therapy. NA #8 indicated she had just placed Resident #18 on a bedpan. Interview with NA #2 on 2/25/24 at 10:43 AM indicated she was assigned to care for Resident #18 today. NA #2 indicated she works full time and has Resident #18 every day she works. NA #2 indicates that she has not checked for incontinence, provided any incontinent care or morning care for Resident #18 because she had a heavy assignment on this side of the hallway, and they were short staffed. NA #2 indicated she had 9 or 10 total care residents to take care of this morning. NA #2 indicated this was the first chance she had time to come check on Resident #18 because she was with other residents. NA #2 indicated that RN #1 about 5 minutes ago told her that Resident #18 had a bowel movement and needed care. NA #2 indicated this was the first time today since she came in at 7:00 AM she has had a chance to take care of Resident #18. Observation of NA #2 providing care on 2/25/24 at 10:55 AM noted Resident #18 was lying in bed on top of a soaper pad with a disposable blue pad on top of it. Resident #18 had on a disposable yellow/tan brief with a thick purple liner inside the brief. NA #2 removed the inner liner, the disposable brief, the disposable pad, and the soaker pad. Resident #18 had a large bowel movement in the bedpan. NA #2 indicated the purple liner was soaked and the yellow/tan brief was wet from urine. NA #2 provided incontinent care and applied cream. NA #2 indicated that Resident #18's peri area and buttocks were red so she was applying cream. Resident #18's buttocks, coccyx and peri areas were red. NA #2 then placed a yellow/tan brief and added the purple liner inside the brief, applied a blue disposable pad and a cloth soaker pad underneath resident. Interview with NA #2 on 2/25/24 at 11:15 AM indicated that she double briefs Resident #18 because she thought it would absorb more urine and help prevent urinary tract infection. NA #2 indicated she had not been educated on why she should not double brief residents. Observation on 2/25/24 at 1:50 PM identified Resident #18 was yelling I need to go to the bathroom. Interview with the DNS on 2/25/24 at 1:55 PM indicated Resident #18 was incontinent and incontinent care was to be provided every 2 hours. The DNS indicated the residents should only be wearing 1 brief and there was not to be a liner inside of the briefs. The DNS indicated that Resident #18 had dementia but should not be instructed to urinate or have a bowel movement in a brief. The DNS indicated that it was a dignity issue. The DNS indicated if Resident #18 was requesting to use the bathroom the nursing staff should have placed him/her on the bedpan right away and not instructed resident to urinate or have a bowel movement in the brief. Observation on 2/25/24 at 2:00 PM the DNS and LPN #1 requested NA #2 provide incontinent care for Resident #18 while lying in bed. NA #2 removed the covers and Resident #18 was lying on top of a cloth soaker pad with a blue disposable pad onto it. NA #2 proceeded to remove the yellow/tan brief with the thick purple liner inside. LPN #1 noted Resident #18 peri area and inner thighs were red, non blanchable and the coccyx and buttocks were red and blanchable. LPN #1 indicated she would apply antifungal cream and then notify the APRN. Interview with LPN #1 on 2/25/24 at 2:05 PM indicated that Resident #18 should not have double briefed, and staff had been educated prreviously not double brief incontinent residents. LPN #1 indicated the nursing assistants should not double brief residents due to extra moisture that would cause the skin to breakdown. LPN #1 indicated Resident #18 should have been placed on the bedpan every 2 hours. LPN #1 indicated that residents should not be double briefed for dignity. LPN #1 indicated she would start the education on not telling residents to urinate in their briefs for dignity and not to double brief for skin care. Inservice Form dated 2/25/24 identified residents with dementia that request to use the bathroom or want to be toileted need to be placed on a bedpan. Residents should never be double briefed or have a liner placed inside of a brief. Signed as educated was RN #1 and NA #2. Inservice Form dated 2/25/24 identified incontinent residents need to be checked on first rounds when starting the 7:00 AM -3:00PM, 3:00 PM-11:00 PM, and the 11:00 PM-7:00AM shifts. Check residents if need to be toileted or given incontinent care before a meal is served. Education was provided by LPN #1 and RN #1 and NA #2 signed off as educated. After surveyor inquiry, the care plan dated 2/25/24 identified Resident #18 may request to use the bathroom and can inform staff if needs to urinate or move his/her bowels at times. Resident #18 buttocks are red and continue with barrier cream. Interventions included checking and changing resident in the morning before breakfast and offer resident to use the bedpan. Additionally, Resident #18 wears a brief for dignity. Do not pace a pad or another brief, one brief is appropriate and sufficient for his/her incontinence. Residents should not be instructed to eliminate in his/her brief. Resident #18 can use the bedpan. The nurse's note written by Infection Control Nurse (LPN#1), dated 2/26/24 at 11:47 AM identified as a late entry for 2/25/24 identified that this writer was notified by DNS and state surveyor to come to resident's room. assigned nursing assistant present, DNS and this writer observed nursing assistant providing peri-care, assessed resident peri-area and buttocks to be reddened in color, this writer applied barrier cream at this time to peri-area/buttocks. this writer placed resident name in APRN book for follow up when in the facility, floor nurse updated regarding reddened area at this time. House stock order in place. this writer notified wound doctor regarding reddened area and resident was place in wound log follow up when in the building. responsible party notified. this writer will follow up weekly. The APRN note dated 2/27/24 at 1:46 PM identified nursing had asked her to see Resident #18 for a skin concern. Discussed with nursing to start Triad paste for skin concern to coccyx area and to follow up with the wound practitioner. New order to apply Triad paste to affected area coccyx twice a day for 14 days. Nursing to follow up with provider for re-evaluation and follow up with wound practitioner as well. Resident #18 care card not dated identified resident was incontinent and used a brief. Review of facility Incontinent Care Policy identified was to promote cleanliness and comfort. Incontinent care is performed by nursing staff on all residents who are incontinent. Residents are checked every 2 hours for incontinence. Incontinent care is provided following episode of incontinence and as needed. Briefs applied per plan of care and changed with incontinent care. Review of the facility Brief guide identified the wetness indicator is designed to help staff identify when a resident has urinated and detects moisture inside the brief to be changed. Review of the facility Resident [NAME] of Rights policy identified the resident has the right to be treated with consideration, respect and full recognition of their dignity and individuality. 2. Resident # 302 was admitted to the facility on [DATE] with diagnoses that included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. A physician's order dated 2/16/24 directed Resident #302 required Lagevrio (an antiviral medication for Covid 19) 800 mg twice daily for 5 days. The care plan dated 2/19/24 identified Resident #302 required staff assistance with activities of daily living (ADLs). Interventions included assisting with mouth/dental care. The care plan also identified Resident #302 was admitted with Covid 19. Interventions included to assist in meeting all ADLs needs as needed. Observation and interview with Resident #302 on 2/25/24 at 7:54 am identified that he/she had several issues with the facility addressing his/her personal hygiene needs. Resident #302 identified that he/she had not been able to brush his/her teeth from admission to the facility on 2/16/24 until 2/21/24, 5 days after admission to the facility. Resident #302 identified that he/she required set up and some assistance with dental care due to muscle spasticity in both arms due to cerebral palsy. Resident #302 further identified that he/she was only to provided the ability brush his/her teeth after a family member called the facility upset regarding Resident #302 not being able to brush his/her teeth that the facility then assisted. Resident #302 also identified that he/she had not had a shower since admission on [DATE]. Resident #302 identified the facility staff would provide assistance with a bed bath but Resident #302 did not feel clean and wanted a shower. Resident #302 identfied he/she had not been offered one at all and believed this was due to his/her covid diagnosis. Resident #302 identified that he/she had been cleared from Covid precautions on 2/22/24. During this interview, Resident #302 was observed with dried white flaky debris throughout his/her face, throughout the exterior visible areas of the ears, and scalp. Resident #302's hair also appeared to have several large flakes of dried white debris within his/her hair, and the hair itself appeared to have a large amount of grease or oil. Resident #302 identified he/she had asked to have a shower since admission and that all requests were ignored by facility staff, including the DNS. Resident #302 identified that he/she had felt ignored and I don't feel like I am being treated like a human being. It's a basic human right to be able to wash myself and brush my teeth. It's not right. Review of the unit shower list for 2/25/23 for Resident #302's unit identified that Resident #302 was to receive showers every Tuesday on the 7 AM-3 PM shift. Review of the resident care card from 2/25/24 for Resident #302 identified Resident #302 required assistance with bathing, preferred showers, and was scheduled for showers every Tuesday on the 7 AM-3 PM shift. Review of the nurse aide task documentation identified that Resident #302 did not have any dental care completed from 2/16-2/21/24. Further review of the nurse aide task documentation from admission to the facility on 2/16/24 through 2/25/24 at 10 AM failed to identify Resident #302 was provided any showers during his/her admission at the facility, a total of 10 days. Interview with LPN #4 and Resident #302 on 2/25/25 at 10:30 AM identified that she was not aware Resident #302 had not had a shower since admission to the facility. Resident #302 identified to LPN #4 I don't know why you guys didn't give me a shower yet. It's my right. I couldn't even get my teeth brushed here. LPN #4 then identified I had not idea that you (Resident #302) had not received a shower. We will make sure you get one today. I am sorry. Interview with NA #1 on 2/25/24 at 10:35 AM identified that she was assigned to care for Resident #302 but that this was the first day she had cared for him. NA #1 identified that LPN #4 notified her that Resident #302 was to have a shower before the end of the shift. Subsequent to surveyor inquiry, Resident #302 received a shower on 2/25/24 during the 7 AM-3 PM shift. Interview with the DNS on 2/26/24 at 8:59 AM identified that she was aware Resident #302 had an issue with getting his/her teeth brushed but was not aware that Resident #302 had also not received a shower. The DNS identified that Resident #302 was upset about not being provided a toothbrush, toothpaste, or being assisted with teeth brushing from admission, and identified she was notified of the issue by a family member of Resident #302 the afternoon of 2/21/24. The DNS identified she was unsure why Resident #302 was not assisted with dental care, and also identified that while Resident #302 was admitted to the facility due to a positive Covid 19 diagnosis, this would not prevent him/her from being able to brush his/her teeth or being able to shower. The DNS identified that the facility would have scheduled Resident #302's shower at the end of the showers for the day, after all other residents had showered, and this was the policy for all facility residents on any precautions so Resident #302 should have received a shower on Tuesday 2/20/24, his/her first scheduled shower day. The facility policy on AM care and ADLs directed that the facility was to provide individualized assistance to residents in preparation for daily activities, according to their wishes and plan of care. The policy further directed that resident's individual preferences and choices would be honored and included in their morning routine, and that AM care and ADLs included assistance with oral hygiene. The facility policy on bathing and showers directed that the facility would provide proper personal hygiene and each resident would be offered a full bath or shower at least weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #18 was admitted to the facility on [DATE] with diagnoses which included fracture of the right femur, dementia, congestive heart failure, and chronic kidney disease. The admission MDS assessment dated [DATE] identified Resident #18 had severely impaired cognition, required maximal assistance with sitting to standing and lying to sitting on the side of the bed, sustained 1 fall with no injury since admission, had an active diagnosis of heart failure, and taking a diuretic. The care plan dated 2/20/24 identified Resident #18 was a fall risk due to multiple risk factors including impaired balance, pain, and unsteady gait. Interventions included the provision of a well-lit and clutter free environment, maintaining commonly used articles within easy reach, and ensuring the call bell remains in reach. The nurse's note dated 2/2/24 at 6:46 AM identified Resident #18 experienced an unwitnessed fall at approximately 6:00 AM, resident denied hitting his/her head and denied pain. Vital signs were obtained. Skin was warm to the touch with no new injuries noted. Range of motion and sensory intact and equal in all extremities excluding the right leg as a result of a previous right femur fracture. Neurological assessments initiated, pupils equal and reactive to light. Resident #18 was assisted back to bed with a two-person assist, education reinforced on the importance of using a call bell. APRN and family were notified. Review of the neurological checks flowsheet and nursing progress notes dated 2/2/24 through 2/5/24 failed to identified neurological checks and vital signs were documented on the following shifts: 2/3/24 from 12:00 PM through 3:00 PM 2/4/24 from 7:00 AM through 3:00 PM 2/4/24 from 3:00 PM through 11:00 PM Review of the post-accident and incident flowsheet dated 2/2/24 through 2/4/24 failed to identify a complete assessment was conducted every shift for 72 hours on the following shifts: 2/4/24 from 7:00 AM through 3:00 PM 2/4/24 from 3:00 PM through 11:00 PM The nurse's dated 2/23/24 at 3:27 AM identified Resident #18 was observed sitting upright leaning against the side of the bed, legs straight, and immobilizer in place to the right lower extremity at 2:15 AM. Resident #18 was alert, verbal, at baseline mentation, denied hitting his/her head, and there was no evidence of injury. Resident #18 indicated I slid right off the bed. Resident #18 had positive circulation, movement, and sensation to all extremities and pupils were equal and reactive to light. Review of the neurological checks flowsheet and nursing progress notes dated 2/23/24 through 2/26/24 failed to identify neurological checks and vital signs were documented on the following shifts: 2/23/24 from 11:00 AM through 3:00 PM 2/23/24 from 11:00 PM through 3:00 AM 2/24/24 from 3:00 AM through 7:00 AM 2/24/24 from 3:00 PM through 11:00 PM 2/25/24 from 3:00 PM through 11:00 PM 2/26/24 from 11:00 PM through 7:00 AM Review of the post-accident and incident flowsheet dated 2/23/24 through 2/25/24 failed to identify a complete assessment was completed every shift for 72 hours on the following shifts: 2/24/24 from 7:00 AM through 3:00 PM 2/25/24 from 3:00 PM through 11:00 PM Interview and clinical record review with the nurse supervisor (RN#4) on 2/26/24 at 2:46 PM, failed to provide documentation that vital signs and assessments (including neurological assessments) were completed per protocol. RN #4 indicated that after an unwitnessed fall assessments, vital signs, and neurological checks should be documented for 72 hours by the nurse that is assigned to that resident. Interview and clinical record review with the DNS on 2/27/24 at 7:07 AM, failed to provide documentation that post-fall assessments (including neurological assessments and vital signs) were completed per facility policy. The DNS identified that it was the responsibility of the charge nurse to complete the assessments, and there was missing documentation on the following days: 2/3/24, 2/4/24, 2/23/24, 2/24/24, 2/25/24, and 2/26/24. The DNS further indicated that she will educate the staff to complete assessments, including neurological monitoring and vital signs, per the facility's fall policy. The facility's Falls: Minimizing Risk of Injury policy directs each time a resident experiences a fall, an Accident and Incident report (A&I) will be completed. Status post A&I assessments and neurological checks will be completed on any resident that experiences an un-witnessed fall and is unable to accurately verbalize if he/she hit head due to cognitive states or experienced any type of head injury. The post A&I assessment and neurological monitoring will be documented x 72 hours. The facility's Neurological policy directs neurological checks will be instituted as a nursing measure following a head injury, TIA, and seizure disorder. A resident that experices an unwitnessed fall and is unable to accurately verbalize if he/she hit their head or experienced any type of head injury will have neurological checks instituted. A neurological check flow sheet will be instituted by the nurse. The checks will be completed as follows: Every 15 minutes for 1 hour Every 4 hours for 4 hours Every 4 hours for 24 hours Every shift for 48 hours The neurological flow sheet shall include the following documentation: Date and time of assessment Level of consciousness Pupillary response Strength and sensation of extremities Vital signs The policy further directs the resident's blood pressure, pulse, and respirations will be checked for significant changes and the nurse will notify the physician if there is any significant change in the resident's neurological status immediately. 4. Resident #18 was admitted to the facility on [DATE] with diagnoses that included fracture of the right femur, dementia, congestive heart failure, and chronic kidney disease. The admission MDS dated [DATE] identified Resident #18 had severely impaired cognition, required maximal assistance with sitting to standing and lying to sitting on the side of the bed, sustained 1 fall with no injury since admission, had an active diagnosis of heart failure, and taking a diuretic. The care plan dated 2/20/24 identified Resident #18 had cardiovascular disease and was at risk for cardiac issues related to atrial fibrillation, CHF, CAD, HTN, and pacemaker. Interventions included labs and xrays to be completed as ordered and results reported, and monitoring for signs and symptoms associated with cardio-respiratory issues and report to the physician or APRN. A physician's order dated 2/19/24 directed to check a Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), and B-type Natriuretic Peptide (BNP) on the next lab day and to monitor for any increased edema and notify the provider of changes. Review of Resident #18's CMP, CBC, and BNP results collected on 2/20/24 identified the following test results outside of the reference range: Hemoglobin (HGB): 8.4 Reference Range: 12.1-15.7 Hematocrit (HCT): 25.5 Reference Range: 35-45 Alkaline phosphatase (ALK PHOS): 218 Reference Range: 35-105 Glomerular filtration rate (GFR): 32 Reference Range: 60-120 Pro-BNP: 4965 Reference Range: 0.0-449.0 Interview and clinical record review with the Nurse Supervisor (RN #4) on 2/26/24 at 2:46 PM failed to provide documentation that the CMP, CBC, and BNP collected on 2/20/24 were signed as reviewed by a physician or documented in a progress note as being reported to a physician, prior to surveyor inquiry. RN #4 indicated that she pulled the lab results directly from the diagnostic lab services portal because they were not in the chart. RN #4 further indicated that she was unaware a physician was notified of the lab results. Interview with the DNS on 2/26/24 at 4:15 PM identified that subsequent to surveyor inquiry the lab results were reported to the APRN and new orders were obtained to monitor Resident #18 overnight, send to the ED for any signs and symptoms of cardiac distress, and to repeat labs in the morning. The DNS further indicated that she was unaware if the results of the CMP, CBC, and BNP were reported to the physician or APRN prior to surveyor inquiry, and that reporting lab results to the medical provider was handled by the charge nurses; she would be notified of abnormal lab results if the resident needed to be sent out to the hospital. The DNS identified that the routine process is for normal lab results that are received via fax to be placed in the communication binder to be reviewed and signed by the medical provider on the following day. The DNS further identified that she would expect any abnormal lab values to be reported to the APRN or the on-call physician, and she would expect to see documentation of the notification in a progress note. Interview with APRN #1 on 2/27/24 at 11:03 AM identified that she was first notified on 2/26/24 of the results of the CMP, CBC, and BNP collected on 2/20/24, subsequent to surveyor inquiry. APRN #1 further identified that the results of the CBC and CMP were consistent with Resident #18's baseline, but she would have expected to have been notified of the BNP with a value of 4965 within 24 hours, if the resident was not presenting with symptoms, and immediately if the resident was presenting with symptoms of cardiac distress. The facility's Change in Resident Condition/Family/MD Notification policy directs that all significant changes in resident's condition will be reported to the physician and family. If the physician is not available, the covering physician shall be notified, and if the covering physician is not available the medical director shall be called. The policy further directs that an RN assessment will be conducted, and the nurse will document in the nurse's note that the physician and responsible party were notified of the change in condition. Although requested a policy of reporting laboratory results was not provided. 5. Resident #25 was admitted to the facility on [DATE] with diagnoses which included COPD, atrial fibrillation, and hypertension. The quarterly MDS assessment dated [DATE] identified Resident #25's cognition was not assessed and was independent with personal hygiene, eating, and walking. The care plan dated 12/6/23 identified Resident #25 was at risk for cardiac issues related to hypertension and atrial fibrillation. Interventions included to administer medications as ordered and assess for symptoms of heart failure such as crackles in the lungs, abnormal heart sounds, neck vein distension, change in mental status, hypotension, diminished peripheral pulses, clammy skin, and frothy sputum and notify the physician. The nurse's note dated 2/12/24 at 5:10 PM identified Resident #25 approached the nurse's station at 3:45 PM complaining of not feeling well. Resident #25 complained of shortness of breath, was pale and weak, blood pressure was 180/80, apical heart rate was 44 and irregular, respiratory rate was 24, and oxygen saturation was 99% on room air. The APRN was notified, and Resident #25 was sent to the emergency room via ambulance at 4:02 PM. Review of the hospital's after visit summary identified Resident #25 was admitted from 2/12/24 through 2/14/24 with severe uncontrolled high blood pressure. The nurse's note dated 2/14/24 at 3:02 PM identified Resident #25 was readmitted from the hospital, accompanied by his/her son, and orders were verified with the APRN. Review of the 2/14/24 nursing admission assessments failed to identify a nursing admission assessment was documented upon Resident #25's readmission to the facility. Review of the 2/14/24 weights and vital signs summary failed to identify vital signs were documented upon Resident #25's readmission to the facility. The nurse's note dated 2/21/24 at 11:53 AM identified that during APRN rounds, Resident #25 was observed to have altered mental status with slurred speech and reported dizziness. Resident #25's blood pressure was 130/80, pulse was 86, respiratory rate was 18, and oxygen saturation was 98% on room air. 911 was activated and Resident #25 was transferred to the emergency room for further evaluation at 10:30 AM. Review of the hospital's discharge summary identified Resident #25 was admitted from 2/21/24 through 2/24/24 with a diagnosis of symptomatic bradycardia. A pacemaker was implanted on 2/23/24 and Resident #25 was discharged in stable condition. The nurse's note dated 2/24/24 at 2:55 PM identified that Resident #25 arrived at the facility at 2:30 PM, from the hospital, accompanied by family members. Resident #25 was alert and oriented, afebrile, and vital signs were stable with no acute distress. According to report, Resident #25 had a single chamber pacemaker implanted on 2/23/24. Review of the 2/24/24 nursing admission assessments failed to identify a nursing admission assessment was documented upon Resident #25's readmission to the facility. Review of the 2/24/24 weights and vital signs summary failed to identify vital signs were documented upon Resident #25's readmission to the facility. Interview and clinical record review with the Nurse Supervisor (RN #4) on 2/26/24 at 2:35 PM failed to identify documentation of nursing admission assessments and vital signs upon Resident #25's 2/14/24 and 2/24/24 readmissions to the facility. RN #4 indicated that she would expect to see vital signs and a nursing admission assessment or a progress note documenting an assessment and vital signs on a resident that left the facility for longer than 24 hours. Interview and clinical record review with the DNS on 2/27/24 at 6:42 AM failed to identify that vital signs and a nursing admission assessment were documented in Resident #25's clinical record on 2/14/24 and 2/24/24. The DNS indicated that it is the responsibility of the charge nurse to obtain baseline vital signs and complete an admission assessment on any resident that was readmitted to the facility after a leave of greater than 24 hours. The DNS further indicated that she plans to in-service the licensed nursing staff on the admission and readmission process including nursing assessments, obtaining vital signs, and writing a progress note. The facility's Admission/readmission of a Resident policy directs the unit nurse will be responsible for completing necessary nursing documentation including nursing assessments, admission narrative note, medication and treatment kardexes. The policy further directs that vital signs, height, and weight are to be completed on admission. 6.Resident #202 was admitted to the facility on [DATE] with diagnoses which included dementia, falls with fracture, and diabetes. The Nursing admission assessment dated [DATE] at 8:40 PM included initial vital signs including height and weight, a body audit for any skin conditions, physical status, functional status, pain assessment, Braden scale assessment, fall risk assessment, oral assessment, smoking assessment, bowel and bladder assessment, gastrointestinal assessment, respiratory assessment, cardiovascular assessment, need for personal hygiene and groom needs, sleep pattern, psychosocial aspects, elopement risk assessment, neurological assessment, side rail assessment and risk factors for readmission assessment. The Nursing admission Assessment was completed by LPN #7 on 2/17/24. Review of the admission Assessments and progress notes dated 2/16/24-2/17/24 did not reflect a registered nurse had any participation in the admission process. The nurse's note written by the DNS dated 2/16/24 at 8:30 PM indicated Resident #202 had arrived at the facility at 8:27 PM accompanied by 2 ambulance attendants. Orders were verified by APRN. The nurse's note written by LPN #7 on 2/17/24 at 5:04 AM identified Resident #202 had arrived after 8:00 PM and was alert with confusion and behavioral disturbances. Resident #202 was admitted with Covid-19 and order for Paxlovid( medication used to treat Covid 19) but needs to be clarified by provider to start and be reconciled. Resident skin is dry and intact with scattered bruises. Interview with the DNS on 2/26/24 at 3:48 PM indicated the admission assessment and body audits can be done by the LPN and the RN just writes a progress note cosigning the admission assessment were completed not for accuracy. The DNS indicated there is not a free-floating supervisor so the LPN has to do her own admission assessments and the RN has a unit so can only cosign that the LPN did the admission assessment not for accuracy. The DNS indicated she on 2/16/24 reviewed the hospital documents under the miscellaneous tab in the electronic medical record at home and from home called the APRN to verify the physician's orders and put her progress note in the electronic clinical record. The DNS indicated she was not at the facility and did not see Resident #202 until 2/17/24. The DNS indicated she did not do any assessments on Resident #202 and there was no documentation or co-signature from an RN for the admission assessment. The DNS indicated that there should have been an RN signature, but it did not happen. 7. Resident # 302 was admitted to the facility on [DATE] with diagnoses that included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. Further review of the assessment identifed it was completed by LPN #3. Review of the clinical record failed to identify any documentation of an initial assessment completed by or reviewed by a RN following Resident #302's admission to the facility on 2/16/24. The care plan dated 2/19/24 identified Resident #302 identified Resident #302 had a diagnosis of Covid 19 with fever. Interventions included monitoring vital signs and providing respiratory modalities as ordered. Interview with the DNS on 2/26/24 at 3:38 PM identified that for new admissions, the LPN charge nurse completed the nursing admission assessments. The DNS identified if there was a free floating RN supervisor, that RN should cosign the LPN admission assessment, however there was often not one and that she cosigned assessments from home, even though she could not confirm if the LPN assessment was accurate as she was not in the facility to see the residents on admission. The DNS also identified that any LPN or RN could call and verify prescriptions with the APRN or MD, but often it was the LPN who was responsible. Review of Resident ##302's clinical record by the DNS identified she did not see any documentation that an RN cosigned or completed an assessment on the residents. The facility policy on nursing documentation directed licensed staff were required to complete an assessment/evaluation of a resident with current changes in health status, and to document the resident's plan of care. Although requested, the facility failed to provide a policy regarding RN assessments for newly admitted residents. 4. The care plan dated 2/19/24 identified the risk for falls. Interventions included to encourage to wear nonskid socks. a. Reportable event form dated 2/18/24 at 10:10 PM Resident #302 was observed kneeling on floor in hallway. Resident #18 had an unwitnessed fall. No injuries noted. Review of the post-accident and Incident form dated 2/18/24 identified there were every shift vital signs for 72 hours but neurological assessments were not completed. Interview with the DNS on 2/26/24 at 2:42 PM indicated she could not find the neurological assessment form for the fall on 2/18/24 starting with every 15-minute vital signs and neurological assessments times 4 times, then every hour for 4 times, then every 4 hours for 4 time. The DNS indicated it was not done. b. Reportable event form dated 2/19/24 at 1:00 PM Resident #302 was found on floor in resident's room. It was an unwitnessed fall. No injuries noted. Review of the neurological Assessment form dated 2/19/24 at 1:15 PM indicated the date and time, temperature, pulse, respirations, blood pressure, pupils if equal and reactive, level of consciousness, strength of extremities, sensation of extremities, and initials of nurse completing assessment. The form indicated the assessment was to be completed every 15 minutes times 4 then every hour times 4 then every 4 hours times 24 hours then every 8 hours times 48 hours. There were 4 dates and times of vital signs and neurological assessments not documented on the form. Interview with the DNS on 2/26/24 at 2:42 PM indicated her expectation was the neurological assessments would have been completed per the form. The DNS indicated she did not know why the fall dated 2/19/24 neurological assessments were not completed. c. Reportable event form dated 2/24/24 at 10:10 PM identified unwitnessed fall in hallway. No injuries noted. Review of the neurological Assessment form dated 2/24/24 at 6:00 PM indicated the vital signs were documented 10 times out of 20 times. The vital signs were documented every 15 minutes times 4 and every hour times 4 then every 4 hours times 2. The neurological assessment was blank 18 out of 20 opportunities. Interview with the DNS on 2/27/24 at 12:00 PM indicated the vital signs and the neurological assessments for the 2/24/24 fall were partially started but not completed. d. Reportable event form dated 2/25/24 at 5:30 AM identified unwitnessed fall in resident's room. No apparent injury. Review of the neurological Assessment form dated 2/25/24 at 5:30 AM indicated the vital signs were taken initially at the time of the fall and documented. The rest of the form was blank. The nurse's note dated 2/25/2024 at 8:54 AM indicated at 5:30am this nurse was called into resident's room. Observed resident lying on the floor near the bed. No apparent injury noted. Interview with the DNS on 2/26/24 at 11:43 AM indicated the charge nurses were responsible to start and complete the neurological assessments after unwitnessed falls. The DNS indicated the charge nurses were to follow the neurological assessment for and take vital signs and do a neurological assessment per the facility policy and the form. The DNS indicated the neurological assessment must be done to pick up on any changes to indicated there was any head injury. The DNS indicated if there were any changes in the vital signs or neurological assessments the APRN or physician must be notified immediately. Interview with the DNS on 2/27/24 at 12:00 PM indicated the vital signs were not completed because the state agency entered the facility. Review of the facility Falls: Minimizing Risk of Injury Policy identified a resident that experiences an unwitnessed fall and is unable to accurately verbalize if he/she hit their head due to cognitive status or experiences any type of head injury will have a neurological check instituted. Each time a resident experiences a fall, an accident and incident report will be completed with a status post A+I assessment and a Neurological monitoring checks will be completed and documented for 72 hours. Review of the neurological Assessment form indicated the date and time, temperature, pulse, respirations, blood pressure, pupils if equal and reactive, level of consciousness, strength of extremities, sensation of extremities, and initials of nurse completing assessment to be completed every 15 minutes times 4 starting at time of fall, then every hour times 4, then every 4 hours times 24 hours, then every 8 hours times 48 hours. Based on observations, clinical record review, facility documentation, facility policy, and interviews for 1 sampled resident (Resident # 2) reviewed for mood and behaviors, the facility failed to ensure a resident had appropriate laboratory monitoring for a prescribed anticonvulsant medication; and for 1 of 5 sampled residents (Resident #36) reviewed for unnecessary medications, failed to ensure a resident receiving insulin and tube feedings had appropriate blood glucose monitoring,and for 1 of 5 residents (Resident #18) reviewed for unnecessary medications, the facility failed to ensure vital signs, assessments, and neurological assessments were completed per facility policy following 2 unwitnessed falls and the facility failed to ensure abnormal lab results were reported to the APRN/physician timely, and for 1 of 4 residents (Resident #25) reviewed for hospitalizations, the facility failed to complete an admission nursing assessment, including vital signs, upon readmission following 2 hospitalizations,and for 2 of 2 residents (Resident #202 and #302) reviewed for accidents, the facility failed to ensure the admission assessment was completed by a registered nurse and failed to ensure that neurological assessments after falls were completed The findings include: 1. Resident # 2 was admitted to the facility on [DATE] with diagnoses which included spastic cerebral palsy, neurogenic bladder, and psychotic disorder with delusions. A physician's order dated 8/25/22 directed Resident #2 required Depakote (a seizure and mood stabilizing medication) 500mg daily at 9 AM and 1000 mg daily at 5 PM for cerebral palsy. The care plan dated 6/12/23 identified Resident #2 had a history of cerebral palsy and psychiatric diagnoses. Interventions included ongoing evaluation of the effectiveness of current psychotropic medications on target symptoms. The quarterly MDSassessment dated [DATE] identified Resident # 2 had severely impaired cognition, was always incontinent of bowel, required an indwelling urinary catheter and dependent on staff for assistance with transfers, bathing, and dressing. Review of the clinical record on 2/25/24 failed to identify any laboratory results related to monitoring valproic acid levels, used to monitor Depakote levels, for 2023 or 2024 for Resident #2. Review of the pharmacy recommendations for 2023 and 2024 failed to identify any recommendations related to Depakote and laboratory monitoring for Resident #2. Interview with MD #1 (Medical Director) on 2/26/24 at 10:37 AM identified Resident #2 was receiving Depakote related to cerebral palsy spasticity and that residents should have valproic acid levels checked, regardless of if the medication was given for a physical or mental health diagnosis, every 6 months. Review of Resident #2's paper and electronic clinical records with MD#1 failed to identify orders or documentation related to monitoring valproic acid levels. MD #1 identified that while it was the prescriber's responsibility to monitor and order lab work, he and APRN #1 relied on the pharmacy recommendations to prompt a reminder that the lab monitoring was needed. MD #1 identified if a resident was stable on the medication, had not recently started the medication, or had a recent dose change, then he likely would not be triggered to order the laboratory monitoring. The facility policy on suggested laboratory monitoring perimeters for Depakote directed that serum valproic acid concentrations should be checked 2 weeks after initiation of the medication, dose changes, and then every 3 months. The policy further directed that appropriate laboratory monitoring of medication required consideration of many factors, including current standards of practice. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses which included malnutrition, gastrotomy, and diabetes. Review of the hospital discharge documentation identified Resident #36 was hospitalized from [DATE]-[DATE] and required multiple open abdominal surgeries, tracheostomy placement and decannulation, gastrostomy tube placement, and required tube feedings and insulin daily. Review of the Discharge summary dated [DATE] identified that Resident #36 was on a diabetic carb counting 75 gram per meal 2000-2400 kcalorie diet, required tube feedings with Jevity 1.5 kcalorie at 75 cc/hr from 6pm-6am, nutritional supplements with breakfast and dinner, Prosource (a protein supplement) 3 times daily, and Juven (a wound healing nutritional supplement) twice daily. The discharge summary also identified that Resident #36 had discharge medications that included Lantus (a long acting insulin for diabetes) 12 units sc (injected subcutaneously) twice daily; Jardiance (an oral diabetic medication) 10 mg once daily; Lispro (a short acting insulin for diabetes) 4 times daily, with sliding scale perimeters between 3-11 units. Review of the clinical record failed to identify any documentation of an initial assessment completed by or reviewed by a RN following Resident #36's admission to the facility on 1/17/24. The physician's orders dated 1/18/24 directed Resident #36 required Jevity 1.5 Kcal (a tube feeding supplement) at 75 cc/hr from at 6 PM to 6 AM; Jardiance 10 mg once daily; Lantus 12 units sc twice daily; and a regular diet with level 3 texture and thin liquid consistency. Review of the clinical record failed to identify any blood glucose monitoring orders for Resident #36. A note dated 1/18/24 at 2:22 PM by APRN #1 identified Resident #36 was seen for new admission to the facility. APRN #1 identified that Resident #36 had a history of diabetes and medications included Lantus 12 units sc twice daily and Jardiance 10 mg daily, and that Resident #36 had a blood glucose of 146 on 1/17/24 at 8:43 PM. The treatment plan included continuing medications, monitor blood glucose and hemoglobin A1C. A nutritional assessment dated [DATE] at 9:02 AM identified that Resident #36 had diagnoses that included malnutrition, muscle and fat wasting, and diabetes. The assessment identified that Resident #36 had a 30 lb or 15.3% weight loss during hospitalization. Nutritional recommendations to adjust tube feeding, protein needs, and oral intake based on labs. A note dated 1/19/24 at 11:07 AM by APRN #1 identified Resident #36 was seen for G tube issues. APRN #1 identified that Resident #36 had a history of diabetes and medications included Lantus 12 units sc twice daily and Jardiance 10 mg daily, and that Resident #36 had a blood glucose of 116 on 1/19/24 at 7:01 AM. The treatment plan included continuing medications, monitor blood glucose and hemoglobin A1C. Further review of the APRN note identified that APRN #1 documented an addendum on 1/19/24 at 5:16 PM following the facility notification of that Resident #36 had a blocked G tube. APRN #1 identified Resident #36 would be transferred to the hospital for evaluation. A note dated 1/22/24 at 12:17 PM by APRN #1 identified Resident #36 had been readmitted to the facility following issues with a G tube. APRN #1 identified the G tube was functioning well and that Resident #36 had a blood sugar 116 on 1/19/24 at 7:01 AM. The treatment plan included continuing medications, monitor blood glucose and Hemoglobin A1C. Review of all additional clinical notes from APRN #1 dated 1/23, 1/24, 1/25, 1/31, 2/5, 2/7, 2/8, 2/12, 2/14, and 2/22/24 all contained duplicate documentation related to Resident #36's blood glucose on 1/19/24 along with the treatment plan including monitoring blood glucose, diabetic medications, and plan including glucose monitoring. Interview with the DNS on 2/26/24 at 8:59 AM identified that she was not aware that Resident #36 did not have regular blood glucose levels checked, but that it would be up to the provider to determine if a resident required regular blood glucose levels. The DNS identified that for some residents of the facility, the providers did not routinely check [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records, facility policies, and interviews for 2 of 3 residents (Resident #5) reviewed for pressure ulcers, the facility failed to complete weekly body audits and weekly Braden scales per the physician's order and failed to ensure a nurse assessment was documented upon identification of a new pressure wound and (Resident #8) the facility failed to complete weekly body audits, per the physician's order. The findings include: 1.a Resident #5 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, multiple sclerosis, and paraplegia. A Physician's order dated 7/3/23 directed to complete a body audit and Braden scale on shower days, every Monday, and document on the assessment tab. The quarterly MDS assessmet dated 11/22/23 identified Resident #5 had intact cognition, the presence of 1 stage 4 pressure ulcer, was always incontinent of bowel and bladder, and was dependent with toileting and bathing. The care plan dated 12/5/23 identified Resident #5 was at risk for skin breakdown due to decreased mobility, incontinence, and history of pressure ulcer to buttocks. Interventions included inspection of skin when providing care for signs and symptoms of breakdown, completion of a Braden scale per facility policy. Review of the Braden scale documentation dated 12/1/23 through 2/25/24 failed to identify Braden scale assessments were completed on the following dates: 12/4/23, 12/11/23, 12/25/23, 1/1/24, 1/8/24, 1/22/24, 1/29/24, and 2/19/24. Review of the weekly body audit documentation dated 12/1/23 through 2/25/24 failed to identify weekly body audits were completed on the following dates: 12/4/23, 12/25/23, and 1/1/24. Interview with LPN #3 on 2/26/24 at 2:00 PM identified Resident #5 has never refused wound treatment, Braden scale assessments, or weekly skin audits under her care. LPN #3 further identified that in her experience, Resident #5 is compliant with most treatments with the exception of taking the house supplement. Interview and clinical record review with the Nurse Supervisor (RN #4) on 2/26/24 at 2:12 PM failed to provide documentation that Braden scale assessments were completed on: 12/4/23, 12/11/23, 12/25/23, 1/1/24, 1/8/24, 1/22/24, 1/29/24 and 2/19/24 and that weekly body audit assessments were completed on 12/4/23, 12/25/23 or 1/1/24. RN #4 indicated that she would expect to see weekly body audits and Braden scale assessments completed weekly on Resident #5, per the physician's order, and that it would be the responsibility of the nurse assigned to the resident to complete both assessments, on the assigned day. Interview and clinical record review with the DNS on 2/26/24 at 2:12 PM failed to provide documentation that Braden scale assessments were completed on: 12/4/23, 12/11/23, 12/25/23, 1/1/24, 1/8/24, 1/22/24, 1/29/24 and 2/19/24 and that weekly body audit assessments were completed on 12/4/23, 12/25/23 or 1/1/24. The DNS indicated that she would expect to see weekly body audits and Braden scale assessments completed on shower days, per the physician's order, and that it would be the responsibility of the charge nurse assigned to the resident to complete both assessments. The DNS further indicated that she would educate the licensed staff on completing weekly body audits and Braden scale assessments, per the physician's order. The facility's Wound Prevention/Interventions For All Residents policy directs that interventions are directed toward minimizing and/or eliminating any negative effects of the causal/contributing factors such as pressure, moisture, friction/shear, and poor nutrition for all residents admitted to the facility. Weekly body audits are completed on bath/shower day by a licensed nurse. b. A Physician's order dated 9/1/21 directed to complete a body audit on shower days, every Friday, and document on the body audit sheet. Review of the weekly body audit documentation dated 5/29/23 identified moisture-associated skin damage (MASD) to Resident #5's sacrum. Review of the nurse's notes dated 5/29/23 failed to identify documentation of a nursing assessment, including size, appearance, and condition of the surrounding skin. The nurse's notes further failed to identify that the physician was notified, and interventions were implemented. A nurse's note dated 6/2/23 at 9:57 PM identified an excoriated area noted to Resident #5's sacrum, new order for Triad paste, and he/she denied pain or discomfort. A wound care specialist progress note dated 6/5/23 identified Resident #5 was seen for a wound consultation for MASD to the sacrum; an open wound was noted and received a status of not healed. The initial wound measurement was 2.5cm x 2cm x 0.1cm, there was a small amount of serous drainage noted, no odor, the periwound skin moisture was normal and exhibited excoriation and erythema, and Resident #5 reported wound pain at a level of 3/10. The quarterly MDS assessment dated [DATE] identified Resident #5 had intact cognition, had 1 stage 4 pressure ulcer, was always incontinent of bowel and bladder, and was dependent with toileting and bathing. The care plan dated identified 12/5/23 identified Resident #5 was at risk for skin breakdown due to decreased mobility, incontinence, and history of pressure ulcer to buttocks. Interventions included inspection of skin when providing care for signs and symptoms of breakdown, completion of a Braden scale per facility policy. Interview and clinical record review with the DNS on 2/27/24 at 6:28 AM identified she completed Resident #5's weekly skin audit on 5/29/23 but failed to provide documentation of a complete wound assessment and physician notification. The DNS indicated she could not recall why she did not write a progress note, but she did notify the medical provider on 6/2/23 and obtained an order for Triad paste. The DNS further indicated the physician should have been notified when the MASD was first identified on 5/29/23 as she may have given orders for an intervention. The DNS identified that she could not recall why the physician was not notified timely, but in situations where she is assisting the nursing staff with assessments she would report her findings to the charge nurse, and she would expect her to notify the provider; if the charge nurse communicated to her that she did not have time to notify the physician then she would make the notification herself. The DNS indicated that she always follows up with the charge nurse the following day or day after to ensure the notification to the provider was made. The facility's Wound and Skin Care Documentation policy directs a complete wound assessment and documentation will be done weekly on each area until healed utilizing the skin/wound tracking record: site/location, stage, size, appearance of the wound bed, undermining/tunneling, surrounding skin, and drainage/exudate. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, cerebral infarction, and dementia. A physician's order dated 5/5/21 directed for a licensed nurse to complete a body audit on shower days, every Wednesday on the evening shift, and document in the electronic health record. The quarterly MDS assessment dated [DATE] identified Resident #8 had severely impaired cognition, had 1 stage 3 pressure ulcer, was occasionally incontinent of bladder, always incontinent of bowel, and was dependent with bathing. The care plan dated 1/2/24 identified Resident #8 was at risk for skin breakdown related to altered mobility and incontinence. Interventions included skin inspection when providing care for signs and symptoms of breakdown, complete treatments as ordered, and complete weekly skin and Braden assessments, per policy. Review of the weekly body audit documentation dated 12/1/23 through 2/25/24 failed to identify weekly body audits were completed on the following dates: 12/20/23, 1/3/24, 1/17/24, 1/24/24, 2/7/24, 2/14/24, and 2/21/24. Interview and clinical record review with the Nurse Supervisor (RN #4) on 2/26/24 at 2:24 PM identified Resident #8 had a pressure ulcer that resolved on 1/17/24; the clinical record failed to provide documentation that weekly skin audits were completed on 1/3/24, 1/17/24, 1/24/24, 2/7/24, 2/14/24, and 2/21/24. RN #4 indicated that she would expect to see weekly body audits completed, per the physician's order. RN #4 further indicated that weekly skin audits would be of particular importance for Resident #8 because he/she had a history of a recent pressure ulcers. RN #4 further indicated that it would be the responsibility of the nurse assigned to the resident to complete weekly skin audits, on the assigned day. Interview and clinical record review with the DNS on 2/27/24 at 6:21 AM failed to provide documentation that weekly skin audits were completed on 1/3/24, 1/17/24, 1/24/24, 2/7/24, 2/14/24, and 2/21/24. The DNS indicated that she would expect that weekly body audits are completed by the charge nurse per the physician's order and facility policy. The DNS further indicated that she would expect the area of the healed pressure ulcer to be assessed during the weekly body audits. The DNS further indicated that she would educate the licensed staff on completing weekly body audits, per the physician's order. The facility's Wound Prevention/Interventions For All Residents policy directs that interventions are directed toward minimizing and/or eliminating any negative effects of the causal/contributing factors such as pressure, moisture, friction/shear, and poor nutrition for all residents admitted to the facility. Weekly body audits are completed on bath/shower day by a licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #21) reviewed for respiratory care, the facility failed to follow physician's orders for routine cleaning and maintenance of the Cpap. The findings include: Resident #21 was admitted to the facility with diagnoses which included cancer, chronic pain, diabetes, and sleep apnea. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition was not completed and required no assistance with dressing and personal hygiene. Additionally, the MDS did not indicate Resident #21 utilized a Cpap. The November 2023 care plan did not identify the use of a Cpap. A physician's order dated 11/24/23 directed to apply Cpap at bedtime with a medium full-face mask at bedtime for sleep apnea, clean nasal and full-face mask with soap and water every morning, clean the non- disposable tubing with soap and water once daily on 7:00 AM-3:00 PM shift. Clean the headgear and masks every month on the first Saturday and as needed. Disinfect humidifier chamber with 1/2-part vinegar and 1/2 part distilled water every week on Saturday 7:00 AM-3:00 PM. Disinfect facemasks and non-disposable tubing with 1/2-part white vinegar and 1/2 part sterile or distilled water for 30 minutes every Saturday on 7:00 AM-3:00 PM shift. Observation on 2/25/24 at 7:48 AM identified Resident #21 was lying in bed with cpap mask on. Observation on 2/25/24 at 8:15 AM identified Resident #21 was lying in bed with cpap mask lying on bed to the right of the resident. Observation on 2/25/24 at 10:30 AM identified Resident #21 was lying in bed with the cpap machine on the nightstand and the cpap tubing was draped over a hook off of the over bed light with the mask hanging off of it, without the benefit of being stored in a bag. Interview with Resident #21 on 2/25/24 at 12:36 PM indicated in the last year no one from the nursing staff have washed or cleaned any part of his cpap machine daily, weekly, or monthly. Resident #21 indicated he/she has been using the supplies he/she had from home to change the mask, tubing, filters, and water chamber. Resident #21 indicated he/she was worried because he/she was almost out of supplies and his/her provider from home indicated he/she was not eligible to receive replacement equipment and when he/she spoke with the nursing staff and the DNS at the facility they tell him/her the homecare agency needs to provide the replacement equipment for the cpap and that the facility would not order it. Observation on 2/26/24 at 9:00 AM identified Resident #21 was lying in bed with cpap machine on the nightstand to his right and the mask was draped over a hook from the over bed light with a stethoscope also hanging off of the hook without the benefit of being in a stored in a bag. Interview and clinical record review with DNS on 2/27/24 at 7:44 AM indicated approximatley 2 weeks ago the Hospice nurse requested the facility get the cpap supplies for Resident #21 but she informed the Hospice nurse that Hospice was responsible to get the supplies. Interview with Director of Clinical Operations (RN #6) on 2/27/24 at 8:15 AM indicated the facility would call their oxygen company to deliver Resident #21's cpap equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 20) reviewed for pain management, the facility failed to ensure a prescribed narcotic analgesic was available for administration. The findings include: Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and anxiety disorder. The admission MDS assessement dated2/3/24 identified Resident #20 had intact cognition, had spinal stenosis, lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 did not have a care plan for pain, pain management or opioid use. A physician's order dated 2/1/24 directed to administer Hydromorphone 4mg (opioid pain analgesic) for pain every 3 hours as needed, Clonazepam(Klonopin) 0.5mg daily for anxiety, Lidocaine Patch 4% applied daily to lower back for pain, Carisoprodol(Soma) 350mg daily for back spasms, Tylenol 1000mg twice daily for pain, Pregabalin(Lyrica) 150mg three times daily for pain, Tylenol 650mg every 6 hours for pain, and Oxycodone 5mg, (opioid pain analgesic )every 3 hours for lower back pain until Hydromorphone 4mg is available (started 2/23/24). Observation and interview on 2/26/24 at 4:35PM identified Resident #20 to be in continuous movement in the bed, noted facial grimacing, agitation, and an irregular breathing pattern. Resident #20 identified she/he was in extreme pain, describing pain level as 10 out of 10 pain and identified the facility had run out of her/his pain medication (Hydromorphone 4mg) for the second time since admission. Resident #20 indicated a substitution Hydrocodone- Acetaminophen 5mg-325mg was administered a few minutes ago and had no effect. Resident #20 further identified that the pain was so severe stating there's no way I can last through the night like this. Interview with DNS on 2/26/24 at 4:45PM noted Resident #20 was out of Hydromorphone 2mg and the Emergency Box supply was depleted. The nurse's note dated 2/26/24 at 5:08 PM entered by RN #7 identified although 180 tablets of Hydromorphone 2mg were ordered only 30 tablets sent at a time for insurance purposes. RN#7 requested a STAT (immediate) delivery which was received at 7:00PM and one tablet was administered. Interview and clinical record review with RN #7 (evening & night supervisor) on 2/27/24 at 7:20AM, identified she administered Hydrocodone-Acetaminophen 5mg-325mg to Resident #20 on 2/26/24 at 4:00PM with little effect. It was identified that the Hydrocodone-Acetaminophen 5mg-325mg administered had reached its expiration date of 12/23. RN #7 indicated Hydromorphone 2mg arrived from the pharmacy on 2/26/24 at 7:00PM and administered one pill (Hydromorphone 2mg although order was for Hydromorphone 4mg 2 pills) at 7:00 PM. The Controlled Substance Disposition Record identified Resident #20 received 3 doses of Hydromorphone 4mg (2 pills) at the following times during the night: 2/26/24 10:00PM 2/27/24 2:00AM 2/27/24 6:00AM Interview with Resident #20 on 2/27/24 at 6:30 AM identified the pain was present for the evening at a rate of 10 out of 10, but somehow got better during the night. Interview and record review with the DNS on 2/27/24 at 10:00AM identified 120 Hydromorphone 2mg tablets were ordered (60 doses for 4mg) however due to insurance purposes, only 30 can be sent at a time. She was able to get an expedited delivery to address Resident #20's pain. She identified it is her expectation that the charge nurses monitor the volume of medications available for a resident's use, and in the case of narcotics, call the pharmacy when the medication runs low to determine if an existing prescription is on hand for possible next delivery, or if a new prescription is needed to notify the physician or APRN. The policy for pain assessment identified that the physician should be notified if interventions are ineffective and work to develop new approaches that will alleviate discomfort for that individual. A policy was requested for ordering narcotic medications when the inventory is depleted, none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #21) reviewed for unnecessary medications, the facility failed to ensure the narcotic disposition record was accurate. The findings include: Resident #21 was admitted to the facility with diagnoses that included cancer, chronic pain, and diabetes. The quarterly MDS assessment dated [DATE] identified Resident #21 did not reflect cognition and pain. A physician's order dated 11/24/23 directed to apply 2 Fentanyl transdermal patch 100 mcg/hour and one Fentanyl 25 mcg/hour patch for a total of 225mcg/hour apply 3 patches transdermal every 72 hours for pain management and remove per schedule. A physician's order dated 1/17/2024 directed for removal and destruction of Fentanyl patches with 2 licensed staff. A review of the controlled substance disposition records for Fentanyl Transdermal patch dated 11/30/23 through February 2024 identified that two nurse's were not consistently signing off on the narcotic disposition record when the patch was removed. Interview with the DNS on 2/26/24 at 9:00 AM indicated that 2 nurses must sign off the removal and destruction of Fentanyl patches on the narcotic sheets. The DNS indicated she could not find the narcotic sheets for the Fentanyl 25 mcg for the period of 12/15/23-1/17/24 and the Fentanyl 100 mcg sheet for the period of 1/1/24-1/7/24 and 2/4/24-2/22/24 for Resident #21. Interview with the DNS on 2/26/24 at 1:00 PM indicated she had found the missing narcotic sheets and gave a second copy of the earlier narcotic sheets for Resident #21's Fentanyl 25mcg and 100mcg for the date requested. Interview with the DNS on 2/26/24 at 4:31 PM indicated 2 nurses must sign of when discarding a fentanyl patch. Review of the second set of Fentanyl patch sheets and the missing Fentanyl sheets the DNS had found indicated there were dates with one signature. The blank spaces from the narcotic sheets from in the morning that were blank later today are now filled in by the DNS. The DNS indicated she today had signed off as the second nurse as disposing of the Fentanyl patches because she knew that they had to have a second nurses' signature and did not want to get into trouble for not having it done. The DNS indicated she had signed today as discarding the fentanyl patches for the following sheets: Fentanyl 100 mcg 2 patches on 1/23, 1/26, 1/29, 2/19, and 2/22/24. Fentanyl 25 mcg discarding 1 patch on 12/3/23, 2/1 and 2/22/24. After review of the narcotic sheets for Resident #21, the DNS indicated she did falsify the narcotic destruction sheets by adding her signature today as the nurse destroying the Fentanyl patches from 8 times from 1/23/24-2/22/24. Review of the facility Administration and Disposing of Fentanyl Transdermal Systems identified Disposal method must have 2 nurses or a nurse and another professional witness the disposal of used and unused patches. Although requested a policy for accurate nursing documentation it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 resident's(Resident #4 and Resident #21) reviewed for respiratory care, the facility failed to sanitize the glucometer after use and store nebulizer tubing and CPAP face mask in a sanitary manner. The findings include: 1. Resident # 4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease (COPD), with a readmission 2/23/24. The admission MDS assessment dated [DATE] identified Resident # 4 had intact cognition, required substantial assistance with sitting to lying in the bed, and toileting. The MDS also identified Resident #4 had anxiety disorder and depression. The care plan dated 2/14/24 identified a concern with diabetes, with interventions which included fingerstick as ordered by the physician and as needed. A physician's order dated 2/4/24 directed to check blood glucose level twice daily at 6:00AM and 6:00PM and to notify the physician if blood sugar is greater than 200mg/.dl. Observations on 2/25/24 at 6:25 AM identified RN# 2 administering a fingerstick securing a reading of 104mg/dl. RN# 2 proceeded to clean the glucometer with a sterile alcohol swab. She indicated the alcohol swap was acceptable to clean the glucometer as every resident is assigned their own glucometer upon admission. When asked about the facility's policy for cleaning glucometers, RN #2 identified that she did not know. Also observed as RN#2 attempted to administer the nebulizer treatment to Resident #4, the surveyor inquired about the date on the tubing and the nebulizer mask not bagged. RN #2 stopped the administration, identified she did not know why the mask was not bagged or the tubing not dated. She proceeded to secure a new mask and tubing and provided the treatment as ordered. An interview with DNS on 02/27/24 at 10:30AM noted there is not currently a separate policy for glucometer cleaning for the facility, even though each resident is assigned their own glucometer. She indicated the glucometer should be cleaned with the appropriate antiseptic wipe, maintaining the manufacturer's guidelines. She further identified alcohol is not an appropriate means of disinfecting the glucometer once used. The DNS also indicated that the tubing for nebulizer treatments should be changed and dated weekly, and the mask should also be bagged when not in use. The facility's policy for glucometer disinfection states the glucometer should be cleaned and disinfected after each use with an approved disinfectant as identified. 2. Resident #21 was admitted to the facility with diagnoses which included cancer, chronic pain, diabetes, and sleep apnea. The quarterly MDS assesment dated 11/9/23 identified Resident #21 cognition was not completed and required no assistance with dressing and personal hygiene. Additionally, the MDS does not identify Resident #21 utilizes a Cpap. The care plan not dated does not identify Resident #21 utilizes a CPAP. A physician's order dated 11/24/23 directed to apply CPAP at bedtime with a medium full-face mask at bedtime for sleep apnea, clean nasal and full-face mask with soap and water every morning, clean the non- disposable tubing with soap and water once daily on 7:00 AM-3:00 PM shift. Clean the headgear and masks every month on the first Saturday and as needed. Disinfect humidifier chamber with 1/2-part vinegar and 1/2 part distilled water every week on Saturday 7:00 AM-3:00 PM. Disinfect facemasks and non-disposable tubing with 1/2-part white vinegar and 1/2 part sterile or distilled water for 30 minutes every Saturday on 7:00 AM-3:00 PM shift. Observation on 2/25/24 at 7:48 AM identified Resident #21 was lying in bed with cpap mask on. Observation on 2/25/24 at 8:15 AM identified Resident #21 was lying in bed with cpap mask lying on bed to the right of the resident, not bagged. Observation on 2/25/24 at 10:30 AM identified Resident #21 was lying in bed with the cpap machine on the nightstand and the cpap tubing was draped over a hook from the over bed light with the mask hanging from it, without the benefit of being bagged. Interview with Resident #21 on 2/25/24 at 12:36 PM indicated that in the last year no one from the nursing staff has washed or cleaned any part of his cpap machine. Resident #21 indicated he/she has been using the supplies he/she had from home to change the mask, tubing, filters, and water chamber. Resident #21 indicated he/she was worried because he/she was almost out of supplies and his/her provider from home indicated he/she was not eligible to receive replacement equipment and when he/she spoke with the nursing staff and DNS at the facility they tell him/her that the homecare place needs to provide the replacement equipment for the cpap that the facility would not order it. Observation on 2/26/24 at 9:00 AM identified Resident #21 was lying in bed with cpap machine on the nightstand to his right and the mask was draped over a hook from the over bed light with a stethoscope also hanging from the hook without the benefit of being in a bag. Interview with Resident #21 on 2/26/24 at 1:00 PM indicated that this morning someone had dropped off a bag on his/her nightstand but did not inform him/her what it was for. Resident #21 indicated that the facility had never in over a year gave him/her a bag to place the face mask in. Resident #21 indicated that he/she believes it is to put his/her mask in, but no one educated him/her or stated what it was for. Resident #21 pointed to the mask and showed it was still hanging off the hook from the overbed night light and the bag was on the nightstand. Interview and clinical record review with DNS on 2/27/24 at 7:44 AM indicated Resident #21 was correct in that the weekly cleaning and the monthly cleaning with vinegar was not being done in the last 6 months but that the daily cleaning does not occur but occasionally the nursing staff will taking an alcohol pad and wiping the inside of the face mask. The DNS indicated the charge nurses were responsible to clean the cpap machine and equipment, but she was aware they were not doing it. The DNS indicated that Resident #21 does take off the cpap mask every morning, but it was the responsibility of the nurses to go in and place the mask into a bag every morning. The DNS indicated the face mask should be bagged when not in use. Review of the facility Oxygen and Nebulizer Tubing Changes identified the changing of tubing and bagging is to prevent the spread of infection. The oxygen and nebulizer tubing is to be changed weekly, when visibly soiled and as needed. Oxygen tubing, masks and nebulizer devices will be bagged and labeled with date and initials. The changing of tubing and bagging is to prevent the spread of infection. Any tubing that is not in use will be placed in a bag for storage in the resident's room. Review of the facility Cpap Care Instructions and Cleaning Policy identified guidelines were established to prevent infections. Licensed nursing staff will care for the Cpap unit to ensure they are clean and functioning.

Based on review of facility documentation and interviews, the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 7/2023 through 12/13/2023 (5 months and 2 weeks). The findings include: Interview with LPN #1 on 2/26/24 at 9:15 AM identified she has been employed by the facility since 12/13/23 as the Infection Preventionist (IP), staff development, and the wound nurse. LPN #1 indicated the DNS oversees her at this time. Interview with the DNS on 2/26/24 at 9:30 AM identified she has been in the DNS position for approximately 1 year. The DNS indicated she was aware of the facility not having a dedicated Infection Preventionist between 7/2023 until 12/13/23 (5 months and 2 weeks). The DNS indicated she had oversight of the the infection control program, the staff development, the wound program, supervisor at times, she worked on the floor as a nurse at times, and the DNS position until 12/13/23. The DNS indicated she had been overseeing the infection control program since LPN #6 had resigned her position on 7/3/23 until 12/13/23. The DNS indicated she had been functioning in the role of infection control nurse; however, she has not completed the specialized training in infection prevention and control. The DNS indicated she does not have the infection preventionist certificate that is required for the infection control program. The DNS indicated she had completed the training course on 10/12/23 but never completed the final examination to complete the training and to receive the Nursing Home Infection Preventionist Training Course Certificate. The DNS indicated she completed the training course and received the Infection Preventionist Certificate during survey on 2/25/24 after the survey team had requested for her Infection Preventionist Certificate. The DNS indicated it was difficult to obtain the infection preventionist certificate due to overseeing so many roles during 7/3/23 through 12/13/23. Interview with the Administrator on 2/26/24 at 12:57 PM identified she was aware that the facility did not have a dedicated infection preventionist from 7/3/23 until 12/13/23. The Administrator indicated the DNS was filling the position until LPN #1 came on 12/13/23. The Administrator indicated she was aware that the DNS did not have the Infection Preventionist training and certificate. The Administrator indicated she notified the DNS to complete the Infection Preventionist training course and obtained the Infection Preventionist Certificate. The Administrator indicated she thought the DNS had completed the course and obtained the Infection Preventionist Certificate. The Administrator indicated she was not aware that the DNS did not have the IP certificate. Review of the Infection Preventionist job description identified the Infection Preventionist (IP), is responsible for the infection prevention and control program. The Infection Preventionist must have primary professional training in nursing, medical technology, microbiology, epidemiology, or another related field. The Infection Preventionist is qualified by education, training, and certification. And has completed specialized training in infection prevention and control. The IP must maintain current knowledge in the field of infectious disease and epidemiology. Attend education programs provided by infection control organizations. Collaborate with other infection control professionals. Administration provides adequate resources to assure that the IP participates in continuing education. Policies and procedures are reviewed periodically and revised as needed to conform to current standards of practice or to address specific facility concerns. Review of The Centers for Disease Control and Prevention guidance identified facilities should assign at least one individual with training in IPC to provide on-site management of their COVID-19 prevention and response activities because of the breadth of activities for which an IPC program is responsible, including developing IPC policies and procedures, performing infection surveillance, providing competency-based training of HCP, and auditing adherence to recommended IPC practices. The facility failed to designate a specific individual, with the required training and qualifications, to oversee the infection control program between 7/3/2023 through 12/12/2023, (5 months and 2 weeks).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #4 [NAME] & [NAME] Res #4 was a readmission and upon request for documents, Res #4's care plans were reactivated . Res #20 had 2 careplans one by dietary, the created by the 2nd Activities Director. #4's F655 needs to change to Resident #20. Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 4 residents (Resident #20, #36, #202, and #302) reviewed for accidents, the facility failed to ensure the baseline care plan was completed in a timely manner. The findings include: 1. Resident # 20 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, chronic pain syndrome, and diabetes type 2. The admission MDS assessment dated [DATE] identified Resident #20 had intact cognition, spinal stenosis, lumbar region with neurogenic claudication, and polyneuropathy. Resident #20 had 2 care plans, one from dietary with a focus on obesity, not following diet at home, and the Activities Director with a focus on orientating to the facility with interventions that included a controlled carbohydrate diet, one to one visits and activities calendar activities introduced respectively. An interview with the DNS on 2/27/24 at 10:00AM identified it is her expectation that baseline care plans are established within 48 hours of the admission to the facility. 2. Resident #36 was admitted to the facility on [DATE] with diagnoses that included malnutrition, gastrotomy, and diabetes. Review of the hospital discharge documentation identified Resident #36 hospitalized from [DATE]-[DATE] and required multiple open abdominal surgeries, tracheostomy placement and decannulation, and gastrostomy tube placement during the hospitalization. The hospital discharge documentation also identified Resident #36 required tube feedings and insulin daily. The admission MDS assessment dated [DATE] identified Resident #36 had intact cognition, was always incontinent of bowel and bladder, was fully dependent on staff for toileting, dressing, and bathing, and required set up for eating. Review of the clinical record identified a blank form labeled Baseline Care Plan within Resident #36's paper chart. Further review of the clinical record failed to identify any additional documentation related to a baseline care plan for Resident #36 within 48 hours of admission to the facility on 1/17/24. 3. Resident #202 was admitted to the facility on [DATE] with diagnoses that included dementia, falls with fracture, and diabetes. The baseline care plan dated 2/16/24 identified dietary indicated to maintain weight and fluids but did not indicate the diet, restrictions, food preferences, nutritional goals and if resident needed adaptive equipment. The baseline care plan was not completed by nursing, therapy, social services departments and reviewed with the resident or resident representative. Interview with the MDS coordinator (RN #3), on 2/26/24 at 2:57 PM indicated the licensed nursing staff was responsible to do the baseline care plan on admission and MDS department then oversees it to do the comprehensive care plan. RN #3 indicated the baseline care plan must be done within 48 hours of admission. RN #3 indicated that Resident #202's baseline care plan was not completed due to lack of staff to do it. Interview with the DNS on 2/26/24 at 3:48 PM indicated the baseline care plans were to be completed within 72 hours of admission. The DNS indicated she was aware that the baseline care plans on admission were not being done. The DNS indicated the charge nurses were responsible to do the baseline care plans and MDS RN #3 was responsible to follow up and make sure they were completed. 4. Resident # 302 was admitted to the facility on [DATE] with diagnoses that included Covid 19, cerebral palsy, and sepsis. The nursing admission assessment dated [DATE] identified Resident #302 had no issues with cognition, was continent of bowel and bladder, and required the assistance of 2 staff members with transfers, walking, and repositioning. Review of the clinical record identified a blank form labeled Baseline Care Plan within Resident #302's paper chart. Further review of the clinical record failed to identify any additional documentation related to a baseline care plan for Resident #302 within 48 hours of admission to the facility. Interview and clinical record review with RN #3 (MDS coordinator) on 2/26/24 at 3:05 PM identified she was the staff member responsible for ensuring a comprehensive care plan into a resident's clinical record. RN #3 identifed that the licensed nursing staff were responsible to do the baseline care plan on admission and MDS department would ensure that the base line care plans were completed, and that the baseline care plans were located on paper in the resident's paper chart. RN #3 identitifed that the baseline care plans were not completed for Resident #36 and #302, and that there had been issues with staffing and the workload in the MDS department which resulted in things getting pushed to the side. Interview with the DNS on 2/26/24 at 3:38 PM identified that all residents of the facility should have a baseline care plan completed within 72 hours of admission. The DNS further identified that while the baseline care plan documentation was on paper, it was individualized to each resident's plan of care needs upon admission to the facility, it was the responsibility of the charge nurse to complete the baseline care plan, and that RN # 3 (the MDS Coordinator) was responsible to follow up and ensure the baseline care plans had been completed. The DNS identified that she was aware that there had been issues with the care plans not being completed and had provided in-services of the licensed nursing staff and audits of resident records related to care plans to address the issue. Review of the facility Baseline Care Plans identified the facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.The care plan will guide caregivers to assist residents to achieve or maintain their highest practical level of wellbeing. The baseline care plan must be developed with in 48 hours of a resident's admission, include the minimum information necessary to properly care for a resident including but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy orders, and social services. The facility must provide the resident or resident representative with a written summary of the baseline care plan when the comprehensive set of care plans is completed at the care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 3 residents (Resident #25, #39 and Resident #202) reviewed for care planning,the facility failed to ensure quarterly care plan meetings were conducted, the facility failed to update the care plan reflecting the resident's preferences for provision of care and accusatory behaviors and the facility failed to revise the comprehensive care plan after falls. The findings include: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses which included COPD, atrial fibrillation, and hypertension. The resident care plan sign-in sheet identified care plan meetings with the IDT(inter discilplinary team ) , Resident #25, and his/her Resident Representative occurred on 5/20/22, 8/29/22, and 4/7/23. The quarterly MDS assessment dated [DATE] identified Resident #25's cognition was not assessed and was independent with personal hygiene, eating, and walking. The care plan dated 12/6/23 identified Resident #25 was social and needed to stay active in independent and group activities. Interventions included to ensure staff visit Resident #25 for 1:1 visits, provided a weekly and monthly calendar of programs, ensure Resident #25 remained busy with independent pursuits, and ensure Resident #25 attended resident council and entertainment programs. Interview with Resident #25 on 2/25/24 at 8:50 AM identified that he/she had resided at the facility for many years. Resident #25 further identified that he/she did not recall attending recent care plan meetings but recalled attending them in the past. Interview with the MDS Coordinator (RN #3) on 2/26/24 at 1:18 PM indicated that due to her current workload and per diem status, the resident care conferences were not being held quarterly. RN #3 identified that the resident care plan sign-in sheets were up to date, and that all care plan meetings that occurred would have supporting documentation, including the sign in sheet. Interview with the DNS on 2/27/24 at 7:00 AM identified she was aware that the MDS coordinator was busy and had fallen behind with scheduling the resident care conferences. The DNS further identified that the MDS Coordinator was per diem, and the facility was in the process of interviewing for a full-time position. The DNS indicated that resident care conferences were expected to be held every three months and if there was a change in condition; she would also expect the meetings to include members of the interdisciplinary team, the resident, and a resident representative. Interview with SW #1 on 2/27/24 at 8:52 AM identified that resident care conferences were expected to be held quarterly but that had not consistently been happening. SW #1 further identified that she supported the MDS Coordinator with resident care conferences, but there was no formal system in place for scheduling or implementing the conferences. SW #1 indicated that the facility was getting better about having the resident care conferences, but she would discuss additional opportunities for improvement with the MDS coordinator and the Administrator. The facility's Care Planning policy directs a care conference will be held on or before day 21 from admission and then at least quarterly to discuss the plan of care. The resident and/or family/responsible party will be invited to attend all care plan conferences. 2. Resident #39 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, anxiety disorder, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #39's cognition and mood were not assessed, and he/she required supervision or touching assistance with personal hygiene and was dependent with bathing. The care plan dated 1/16/24 failed to identify Resident #39's preferences for provision of care, interventions addressing customer service concerns brought forth to the facility and accusatory behaviors. Interview with Resident #39 on 2/25/24 at 2:35 PM alleged that NA #3 was rude, handled him/her strongly while providing care, and had directed specific expletive language towards him/her. Resident #39 indicated that other concerns with nursing staff were brought to the attention of the facility, within the last few months. Resident #39 indicated that on 1/6/24 he/she notified the police because an unnamed nurse or nurse aide provided him/her with rough care. Resident #39 further indicated that he/she had reported a male nurse aide to the facility for being loud and laughing; Resident #39 felt the facility addressed the concerns with the male nurse aide because his demeanor had improved. Interview with SW #1 on 2/26/24 at 11:01 AM identified that in December, Resident #39 had requested a room change from the [NAME] Wing to the East Wing because he/she did not get along well with the roommate. Subsequent to the East Wing move, Resident #39 requested to move back to the [NAME] Wing because he/she had developed a relationship with a few of the nurse aides and preferred the manner in which they provided care. Resident #39 returned to the west wing and has not brought forth any concerns related to staff since the move. SW #1 identified that Resident # 39 often requires additional time from the nursing staff and does have an expectation for how care is to be delivered. SW #1 further identified that Resident #39 wants to continue doing things for his/herself that he/she can no longer do, resulting in frustration. SW #1 indicated that she has a good rapport with Resident #39 and his/her daughter and that they communicate frequently, face to face or via email. SW #1 indicated that she was unaware of accusations made by Resident #39 towards staff members, but that he/she had communicated customer service concerns related to some nurse aides, and that Resident #39 does prefer specific staff members and the way they provide care. Interview with the Regional Nurse (RN #6) on 2/26/24 at 3:21 PM identified that Resident #39 had a history of reporting allegations, at the facility that he/she previously resided. RN #6 indicated that Resident #39 is not currently care planned for accusatory behaviors but one will be developed. Interview with the DNS on 2/26/24 at 4:22 PM identified that since Resident #39 moved back to the [NAME] Wing, he/she has identified customer service concerns with 4 staff members. The DNS further identified that Resident #39 should have been care-planned for accusatory behaviors and provision of care preferences. 3.Resident #202 was admitted to the facility on [DATE] with diagnoses that included dementia, falls with fracture, and diabetes. A physician's order dated 2/17/24 directed to ambulate with assist of 2 without a device every shift due to a fall risk. The care plan dated 2/19/24 identified the risk for falls. Interventions included to encourage to wear nonskid socks. Furthermore, the care plan did not reflect the fall on 2/18/24 and 2/24/24, and 2/25/24. The care plan did not reflect the interventions from the fall on 2/19/24 to use floor mats and did not reflect an intervention for the fall on 2/24/24 and 2/25/24. a. The nurse's note dated 2/18/2024 at 2:43 identified Resident #202 was ambulated with assist of 2 to the bathroom. Resident #202 attempted to get out of bed once. Resident #202 noted sliding out the end of the bed. Reportable event form dated 2/18/24 at 10:10 PM Resident #202 was observed kneeling on floor in hallway. Resident #18 had an unwitnessed fall. Intervention directed to have resident wear nonskid socks. The nurse's note dated 2/18/24 at 10:41 PM identified Resident was observed on his/her knees in hallway. Resident had self-transferred self from the bed. b. Reportable event form dated 2/19/24 at 1:00 PM Resident #202 was found on floor in resident's room. The intervention was bedside floor mats to both sides of bed. The nurse's note dated 2/19/2024 at 4:27 PM identified Resident #202 found on the floor to his/her room. Resident #18 had an unwitnessed fall. RN assessment reveals neurologically was alert & confused baseline mentation. c. Reportable event form dated 2/24/24 at 6:00 PM identified unwitnessed fall in hallway. The intervention was offer fluids and nutrition and toilet before changing gown and bed. The nurses note dated 2/24/2024 at 6:00 PM identified Resident #202 status post unwitnessed fall on 2/24 at 6:00 PM. Resident #202 observed in hallway, lying on left side near room door. Resident is alert, and at baseline of cognitive, with increase in confusion, stating along the lines of wanting to help someone out there. No evidence of injury, positive range of motion to all extremities. Observation on 2/25/24 at 6:00 AM Resident #202 sitting in wheelchair tilted backwards in front of the nurse's station with Residents feet exposed without the benefit of nonskid socks. Observation on 2/25/24 at 9:22 AM Resident #202 sitting in wheelchair in residents' room with bare feet and without the benefit of nonskid socks. d. Reportable event form dated 2/25/24 at 5:30 AM identified unwitnessed fall in resident's room. The intervention was offering fluids and nutrition and toilet before changing gown and bed (same intervention as the fall on 2/24/24). The nurse's note dated 2/25/2024 at 8:54 AM Resident #202 at the nurse's station in w/c at beginning of shift stats post fall from 6pm evening shift. Resident #202 was alert and oriented and restless this time. Snacks & fluids offered & taken. Neurological assessment was within normal limits. At 5:30am this nurse was called into the resident's room. Observed resident lying on the floor near the bed. No apparent injury noted. Interview with the DNS on 2/26/24 at 11:43 AM indicated that the nurses were responsible to immediately after a fall to put an intervention in place and care plan the intervention. The DNS indicated the next morning the interdisciplinary team will discuss the fall and make sure the intervention was appropriate or change it. The DNS indicated the reason they put an intervention in place right away was to try to prevent future falls. The DNS indicated the fall on 2/18/24 was not reflected on the care plan. The DNS indicated for the fall on 2/18/24 the intervention should have been put Resident #202 back to bed and should have been safety checks between 10:00 PM -10:30 PM every day and document that on the nursing assistant care card so they know what to do and the care plan. The DNS indicated the intervention of non-skid socks wasn't put into place until 2/19/24 and the safety checks was not on the care plan or on the nursing assistants care card for resident #202. Review of the 2/19/24 fall, the DNS indicated the intervention was to place floor mats on the floor on both sides of the bed. The DNS indicated the expectation was the nurse would put it in the care plan and the nursing assistants care card but indicated it was not on either. Review of the fall on 2/24/24 the DNS indicated the intervention was grey it is not specific just says frequent rounding. The DNS indicate the intervention should have been occupy Resident #202 at 6pm with puzzles and a pencil even though he/she may not know what to do with it to occupy him/her. Review of the 2/25/24 fall, the DNS indicated that the intervention listed on 2/24/24 was the same as the 2/25/24 and she felt it was grey and was not an intervention but what was expected of staff. The DNS indicated the care plan was not updated with the falls on 2/18/24, 2/24/24, and 2/25/24 and the interventions were not updated. Interview with MDS coordinator (RN #3), on 2/26/24 at 2:57 PM indicated the nurses were responsible to put interventions in place right after a fall and place it on the care plans to try to prevent future falls. Review of the facility Care Planning Policy identified to ensure residents have a comprehensive and individualized plan of care. The care plan will include a statement of the problem: reasonable and measurable goals: interventions to achieve these goals and the disciplines responsible to carry out the interventions. The care plan is reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status. The nursing assistants care cards will be updated as needed to reflect changes made to the resident's plan of care. Review of the facility Falls: Minimizing Risk of Injury Policy identified an individualized care plan will be developed and updated as needed to identify interventions to prevent falls and minimize injury. Each time a resident falls the care plan will be revised with any interim interventions to minimize risk of injury. The resident care card shall include the fall risk and preventative strategies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility policy, and interviews, the facility failed to ensure all licensed nurses( 27 ) were certified and had up to date Cardiopulmonary Resuscitation (CPR) cards. The findings include: Review of the facility licensed nurses identified there is a total of 27 licensed nurses on staff (16 Registered Nurses and 11 Licensed Practical Nurses). Review of the CPR binder for licensed nurses identified 19 licensed nurses failed to have valid and up to date CPR cards. The facility had 8 out of 27 licensed nurses with valid and up to date CPR cards on file. Interview and facility documentation review with LPN #1 on [DATE] at 12:00 PM identified she has been employed by the facility since [DATE] as the Infection Preventionist, Staff Development, and Wound Nurse. LPN #1 indicated she had reviewed all licensed nurses CPR cards and was aware that 19 licensed nurses did not have valid and up to date CPR cards on file. LPN #1 indicated she had notified the DNS, Administrator, and RN #6 (Regional Nurse) of the issue. Interview with the Administrator on [DATE] at 1:05 PM identified she was not aware of the issue. The Administrator indicated the DNS did not notify her that the facility failed to pay for the CPR class that was done on [DATE]. Interview and facility documentation review with the DNS on [DATE] at 3:34 PM identified she was not aware of the issue until LPN #1 had brought it to her attention. The DNS indicated she was unable to monitor the licensed nurses CPR cards with the multiple roles that she had to perform. The DNS indicated the Staff Development Nurse was responsible for making sure all licensed staff had a valid and up to date CPR card upon hire and every 2 years thereafter and to have a copy for facility records. The DNS indicated the 8 licensed nurses attended the [DATE] CPR class, however the licensed nurses were unable to receive their CPR cards as the vendor was not paid for the CPR course and certification. Interview with RN #6 (Regional Nurse) on [DATE] at 3:50 PM identified she was not aware that the licensed nurses did not have valid and up to date CPR cards. RN #6 indicated upon hire, Human Resources receives the CPR card and then the Infection Preventionist/Staff Development Nurse was responsible to ensure all licensed nurses were current with their CPR card. RN #6 indicated she was not aware of the [DATE] CPR class and the facility failed to pay for the class. Although requested, a facility policy for CPR certification requirements was not provided.

Based on review of the facility documentation and interviews, the facility failed to ensure 18 of 27 licensed nurses completed annual competencies related to providing Intravenous Therapy (IV) and the facility failed to ensure 14 of 27 licensed nurses had Intravenous Therapy (IV) certificates. The findings include: Review of the State Agency documentation identified the facility has a licensed bed capacity of 60 and an IV therapy program. 1. Review of the facility licensed nurses identified there is a total of 27 licensed nurses on staff (16 Registered Nurses and 11 Licensed Practical Nurses). Interview with LPN #1 on 2/26/24 at 9:15 AM identified she has been employed by the facility since 12/13/23 as the Infection Preventionist (IP), Staff Development, and the wound nurse with oversight from the DNS. Interview and facility documentation review with LPN #1 on 2/26/24 at 11:00 AM identified she was not aware that all licensed staff did not complete IV competencies for the year 2023. LPN #1 and the DNS indicated they were able to locate 9 out of 27 licensed nurse's competencies for the year 2023. LPN #1 indicated she will be contacting the pharmacy IV department and to schedule IV education and competencies immediately. LPN #1 indicated licensed nu. Interview and facility documentation review with the DNS on 2/26/24 at 11:10 AM identified she was not aware of the issue and that LPN #6 was responsible to oversee the staff development position, and the annual education/competencies that were performed between 1/2023 through 3/2023. The DNS indicated she was not aware that licensed nurses were performing IV therapy without an annual IV competencies. 2. Review of the licensed nurses IV certificate log failed to reflect IV certificatation for 14 of 27 licensed nurses. Interview and facility documentation review with LPN #1 on 2/26/24 at 11:12 AM identified 14 of 27 licensed nurses do not have an IV certificate. LPN #1 indicated she will contact the pharmacy IV department and schedule an IV education and certification class. Review of the facility infusion therapy education for licensed nursing and supportive staff policy identified that licensed and supportive nursing staff receive education related to infusion therapy in accordance with the Connecticut Department of Public Health. All licensed staff will be expected to attend and successfully complete an IV management course prior to caring for residents receiving IV therapy. Licensed nursing staff will have IV competencies completed annually. The Staff Development or designee will schedule annual IV education for both licensed nursing staff and supportive staff.

Based on review of facility documents, review of facility policy and interviews, the facility failed to complete performance reviews for 3 of 4 of the nurse aide personnel files reviewed every 12 months as required. The findings include: Facility document review of 4 NA personnel files identified the following: NA #3 personnel file identified she was hired in 2017 and no performance reviews were completed for years 2022 and 2023. NA #4 personnel filed identified he was hired in 2018 and no performance reviews were completed for years 2022 and 2023. NA #5 personnel file identified she was hired in 2013 and performance reviews were completed for year 4/15/23 (An exception rating was identified in 4 categories) no evaluation was completed for 2020, 2021, 2022. NA #6 personnel file identified she was hired 2019 and no performances reviews were completed for years 2020, 2021, 2022, and 2023. Interview on 2/27/24 at 10:00AM with the DNS and Administrator identified they are aware performance reviews were not completed for 2023. The Administrator identified that she is implementing a plan for 2024 with the department heads to have all of the performance reviews completed in a timely manner going forward. Although requested a facility policy for performance reviews was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #352 was admitted to the facility on [DATE] with diagnosis that included a fracture right lower leg, pain right lower leg, and anxiety disorder.The admission MDS assessment dated [DATE] identified Resident #352 had intact cognition, with no mobility documented. The care plan dated 2/25/24 identified a focus on opioid use with interventions that include medications as ordered by physician. The physician's orders dated 2/23/24 included Pregabalin 150mg by mouth one time a day for leg pain. The Controlled Substance Disposition Record for Resident #352 identified on 2/25/24 10 capsules of Pregabalin 150mg were delivered for Resident #352, and on 2/25/24, one was administered at 2:00PM as ordered reducing the count to 9 capsules. On 2/25/24 one Pregabalin 150mg was popped in error reducing the count to 8 capsules, however only one licensed staffed member signed Controlled Substance Disposition Record disposing of the capsule in error. Interview with RN #7 (RN Supervisor) on 2/27/24 at 7:20AM identified 2 nurses should dispose of a controlled substance medication. Interview with the DNS on 2/27/24 at 10:00AM identified it is her expectation that protocols for disposing of a narcotic are followed and 2 signatures are required to dispose of a narcotic. Although requested, a facility policy was not provided on disposing of a controlled substance. 4. Resident # 4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, type 2 diabetes, and chronic obstructive pulmonary disease (COPD), with a readmission 2/23/24. The admission MDS assessment dated [DATE] identified Resident # 4 had intact cognition, required substantial assistance with sitting to lying in the bed, and toileting. The MDS also identified Resident #4 had anxiety disorder and depression. The care plan dated 2/14/24 identified a concern with COPD, with interventions which included if Resident #4 complains of shortness of breath, check lung sounds, vital signs, oxygen saturation level and provide medication as ordered by the physician on an as needed basis and notify the physician or APRN. A physician's order dated 2/2/24 directed to administer Fluticasone-Umeclidin-Vilant Inhalation Aerosol Powder Breath Activated 200-62.5-25 MCG/ACT (Fluticasone-Umeclidinium-Vilanterol) a generic version of Trelegy which is a bronchodilator used to decrease airway inflammation and improve airflow-Give 1 puff by mouth one time a day for asthma. Observations on 2/25/24 at 6:25 AM identified as RN#2 administered care, a container of Trelegy Ellipta 200mcg/62.5-25 was identified on the bedside table. Resident #4 indicated the medication was brought from home. The container appeared to be sealed and unused. RN #2 secured the medication from the Resident #4 and placed it in the medication cart. The prescription indicator was not that of the facility's pharmacy. 5. Resident #28 was readmtted to the facility on [DATE] with diagnosis the included type 2 diabetes, chronic kidney disease stage 4, and left leg below the knee amputation. A physician's order dated 2/1/24 identified that Nystatin External Powder 100000 unit/GM (topical antifungal powder) to be applied to the groin area topically every day and evening for redness and Triad paste to buttock every shift for protection. The quarterly MDS assessment dated [DATE] identified Resident #28 had intact cognition, is a high risk for pressure ulcers and utilizes a pressure relieving mattress. The care plan for Resident #28 had a focus on incontinence of bowel and bladder with interventions to provide treatments as ordered. Observations on 2/25/24 at 11:40AM identified 3 containers of Nystatin External Powder 10000 unit/GM at the bedside table with the following pharmacy dispense dates: 1/25/24, 12/11/23, and one without a pharmacy dispense date. Also located at the bedside was a tube of Triad paste. An interview with DNS on 2/27/24 at 10:00AM noted it is her expectation that medications are secured in a locked cabinet for use by licensed personnel, and any resident who desires to administer their own medications should be assessed and care planned accordingly. She further indicated Triad and Nystatin should be administered by licensed personnel only. The policy on medication storage identified that the facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessibly by residents or visitors. Based on review of the clinical record, facility documentation, facility policy, and interviews for 4 of 5 residents (Resident #21, Resident #352, Resident #4 and Resident #28) reviewed for unnecessary medications, the facility failed to ensure the narcotic destruction was performed per facility policy and the facility failed to ensure medications were not left at the bedside unsecure. The findings include: Resident #21 was admitted to the facility with diagnoses which included cancer, chronic pain, and diabetes. The care plan dated 7/12/23 identifies Resident #21 has moderate to severe pain. Interventions included medications as ordered by the physician. The quarterly MDS assessment dated [DATE] identified Resident #21 cognition and pain were not completed. 1. A physician's order dated 11/24/23 directed to apply 2 Fentanyl transdermal patch 100 mcg/hour and one Fentanyl 25 mcg/hour patch for a total of 225mcg/hour apply 3 patches transdermal every 72 hours for pain management and remove per schedule. A review of the controlled substance disposition records for Fentanyl Transdermal patch dated 11/30/23 through February 2024 identified that two nurse's were not consistently signing off on the narcotic disposition record when the patch was removed. Interview with LPN #3 on 2/26/24 at 7:45 AM identified the fentanyl 25mcg/hour received on 2/12/24 indicated on 2/16/24 that 1 nurse removed old patch not 2 nurses', on 2/19/24 that 1 nurse removed old patch not 2 nurses, on 2/22/24 no nurse signed that they removed the old patch. LPN #3 indicated on the Fentanyl 100 mcg received 2/21/24 that there weren't any nurse's signatures as discarding the patches on 2/22/24. Interview with the DNS on 2/26/24 at 9:00 AM indicated that 2 nurses must sign off the removal and destruction of fentanyl patches on the narcotic sheets. The DNS indicated she could not find the narcotic sheets for the Fentanyl 25 mcg for the period of 12/15/23-1/17/24 and the Fentanyl 100 mcg sheet for the period of 1/1/24-1/7/24 and 2/4/24-2/22/24 for Resident #21. The DNS indicated she would look for the sheets. Interview with the DNS on 2/26/24 at 4:31 PM indicated 2 nurses must sign of when discarding a fentanyl patch. Review of the controlled substance sheets the DNS indicated there were many signature missing. 2. Observation on 2/25/24 at identified Triad Hydrophilic Wound Dress External Paste (Wound Dressings) Apply to coccyx topically three times a day for redness and 2 tubes of Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical) Apply to Affected areas lower legs topically four times a day for rash on Resident #21's overbed table at the bedside. Interview with the RN #1 on 2/25/24 at 8:05 AM indicated the 3 tubes of medicated cream did not belong on Resident #21's overbed table in his/her room. RN #1 indicated the tubes of cream belonged locked up in the treatment cart. RN #1 indicated that Resident #1 was not able to apply any of the creams and that the nurses had to apply them. RN #1 removed the tubes of medicated creams and placed them in the locked treatment cart. Interview with the DNS on 2/27/24 at 7:44 AM indicated that the medicated creams were not to be left at the bedside for Resident #21. The DNS indicated the nurses have to apply the creams for Resident #21. The DNS indicated the creams were to be stored in the treatment cart that was to be locked. Review of the facility Administration and Disposing of Fentanyl Transdermal Systems identified Disposal method must have 2 nurses or a nurse and another professional witness the disposal of used and unused patches. Review of the facility Medication identified medication carts, medication rooms, and cabinets should be locked when unattended. Medications are properly labeled with resident name, lot number, and expiration date. It is the designated staff members responsibility to maintain possession of the keys and security of the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #235) reviewed for fall, the facility failed to notify the physician of a change in condition for a resident who sustained a fall requiring transfer to an acute care facility for an evaluation and in accordance with facility policy. The findings include: Resident #235 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, systolic hypertension, sinus node dysfunction, pacemaker, and dementia. Resident Care Plan (RCP) dated 9/24/21 identified Resident #235 was alert and confused and required assist of two with mobility and transfers. The physician's orders dated 9/24/21 directed the placement of an indwelling Foley catheter. The nursing progress note dated 9/26/21 at 4:56 A.M. identified Resident #235 was found lying on the bedroom floor at 4:30 A.M. which resulted in the resident's Foley catheter partially dislodged and noted bleeding and trauma. Range of Motion (ROM) was noted to the right leg which identified pain to the thigh and the right hip. Resident #235 was resistive to movement and stated it was too painful to complete the assessment. Resident #235 was transported to an acute care facility for Foley catheter replacement and to rule out left hip fracture. The responsible party was left a message regarding the change in the resident's condition. The Reportable Event dated 9/26/21 at 4:30 A.M. identified Resident #235 was found on bedroom floor with the Foley catheter pulled out causing bleeding and trauma. Advanced Practice Registered Nurse (APRN #1) was notified at 4:36 A.M. and Resident #235 was subsequently transported to an acute care facility. Interview with APRN #1 on 10/1/21 at 10:45 A.M. indicated she was not notified of Resident #235's fall. APRN stated she was off duty at the time of the fall and made aware 9/27/21 when she came to the facility. Interview with Registered Nurse (RN #1) indicated that APRN #1 was not notified of Resident #235's fall. RN #1 stated she placed the information in the APRN communication book on the unit and sent Resident #235 out to an acute care facility. Interview with Director of Nursing Services (DNS) on 10/1/21 at 12:30 P.M. indicated that while she completed the Reportable Event form. Although she indicated APRN #1 was notified, she, was not notified. Interview with DNS #1 on 10/1/21 at 12:30 P.M. and with RN #2 and again with the DNS on 10/1/21 at 1:35P.M. identified that an error was made when they filled out the Reportable Event form stating that they were both reviewing the chart and mistakenly indicated APRN #1 was notified. Review of Policy Change in Resident Condition/Family/MD Notification directed all significant changes in resident's condition will be reported to physician and family. The facility failed to notify the physician of a change in condition following a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one of two residents (Resident #4) reviewed for falls, the facility failed to ensure fall quarterly assessments were conducted in accordance with facility policy and the plan of care to prevent future falls. The findings include: Resident #4 was admitted on [DATE] with diagnoses that included chronic kidney disease, adult failure to thrive and anemia. A Fall Risk assessment dated [DATE] identified a score of 4 indicating Resident #4 was not at risk for falling. The annual MDS assessment dated [DATE] identified Resident # 4 required supervised assist with bed mobility, transfers and locomotion in the room. The RCP dated 6/28/21 identified Resident #4 was at risk for falls. Interventions included: to have the call bell within reach when in bed or bedside chair, to encourage the resident to ask and wait for staff assistance for transfers and/or toileting, to reinforce need to use walker to ambulate independently in room and to replace slippers with gripper soles. The Physical Therapy Progress and updated Plan of Care dated 8/9/21 identified Resident #4 was moderately independent with ambulation in his/her room with an assistive device. The physician's orders dated 8/30/21 directed Resident #4 to be independent with ambulation and assistive device (rolling walker.) The Reportable Event dated 8/30/21 identified Resident #4 was alert and oriented, had un unwitnessed fall while ambulating with a rolling walker resulting in a small bruise to the right elbow and indicated the resident had complaint of pain to the right side. A Nursing Progress Note dated 8/31/21 at 11:32 A.M. Resident #4 was found on the floor lying on the right side with the walker lying next to him/her. Resident #4 could not specifically say what happened just that s/he was walking in the room. No obvious injuries noted, with a complaint of pain to the side that was in contact with the floor. No obvious bruising or trauma noted, small bruising to right elbow and skin remained intact. APRN notified and the responsible part were notified. An X-Ray report dated 8/31/21of the right rib showed no fracture or pneumothorax. An interview and clinical record review dated 9/30/21 at 1:25 P.M. with the DNS identified fall assessments for June and September 2021 should have been completed by the unit nurses and were not completed. The facility policy related to Falls: Minimizing Risk of Injury dated 11/2018 directed fall assessments are to be completed upon admission, quarterly and with a significant change of condition. The facility failed to ensure fall assessments were conducted according to policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, review of facility policy and interviews for one out of thirty-three residents (Resident #1) reviewed for staffing, the facility failed to provide a sufficient number of personnel to meet the resident's needs. The findings include: Resident #1's diagnoses included Parkinson's disease, anxiety disorder, hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage and convulsions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was required extensive assistance of two-person physical support for personal hygiene and transfers. The care plan identified the resident requires assistance with all ADL and mobility. Resident uses the following assistive devices: wheelchair. Interventions included for current function status: to provide total assist of 1 person with daily bathing/grooming/mouth care, to transfer the resident with the assistance of two people via Hoyer lift and to encourage out of bed every day for 2 hours on the 7:00 A.M. to 3:00 P.M. shift. Interview with Person #1 on 9/27/21 at 1:52 P.M. identified the facility staff never get Resident #1 out of bed. Person #1 identified he/she has brought her/his concerns to facility staff during care planning meeting discussions. Person #1 further indicated that due to staff turn-over, many things he/she has discussed with the facility has been falling through the cracks. Person #1 identified there is a camera in Resident #1's room, which is how he/she identified Resident #1 is always observed to be in bed instead out of bed. Person #1 also identified Resident #1 does not receive weekly showers secondary to being in bed. Review of the Nurse Aide (NA) Care Card on 9/28/21 at 8:30 A.M. identified for transfers Resident #1 required the assistance of people 2 via Hoyer lift and directed the resident to be out of bed to Geri-chair for 2 hours/day for lunch. The NA care card identified Resident #1 prefers showers, scheduled on Thursdays during the 3:00 P.M. to 11:00 P.M. shift. Observation of the staffing on 9/28/21 during the 7:00 AM to 3:00 PM shift identified 3 nurse aides for 2 units. Each unit had one (1) nurse aide with an additional one (1) nurse aide performing a split assignment. Observations on 9/27, 9/28, 9/29, 9/30 and 10/1/21 during the 7:00 A.M. to 3:00 P.M. shift identified Resident #1 remained in bed without the benefit of getting up to a wheelchair. Resident #1 was given a shower on 9/29/21 and was then placed immediately back into bed without the benefit of being in a chair. Interview with NA #1 on 9/29/21 at 12:25 P.M. identified Resident #1 is a difficult transfer as he/she tends to move aggressively once in the Hoyer. NA #1 indicated it takes 2-3 people to transfer resident, but at times the transfer can be unsafe with 2 staff present. NA #1 identified most times s/he is unable to get Resident #1 out of bed due to staffing. NA #1 identified many times s/he can be the only staff working the whole unit and indicated there's no other staff to assist with transfer. NA #1 identified Resident #1 is unable to vocalize refusal, but actions such as screaming/yelling/thrashing would be conceived as refusal. NA #1 identified behaviors such as these should be reported to the RN and charted as refusals in the electronical medical records. Interview with DNS on 9/29/21 at 1:30 P.M. identified the expectation should be four (4) nurse aides working on the 7:00 A.M. to 3:00 P.M. shift. Interview with NA #2 on 10/1/21 at 10:20 A.M. identified she did not get Resident #1 out of bed yesterday on 9/30/21 during the 7:00 AM to 3:00 P.M. shift due to short staffing, which affected resident's from getting out of bed timely. NA #2 identified if a resident refuse to get out of bed, staff should report the refusal to the RN and documented in the electronic medical records. NA #2 identified there should be 2 nurse aides per unit, but confirmed they are short during the day shift on many occasions. Review of the A.M. Care/ADL Policy identified nursing staff will provide assistance with A.M. care for each resident daily as needed. Residents will be encouraged to participate as much as possible with A.M. care. . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, observations, review of facility policy and interviews for one of two residents (Resident #1) reviewed for Activities of Daily Living (ADL), the facility failed to provide care per resident's preferences and in accordance with the plan of care. The findings include: Resident #1's diagnoses included Parkinson's disease, anxiety disorder, hemiplegia and hemiparesis following non-traumatic intracranial hemorrhage and convulsions. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severe cognitive impairment and was required extensive assistance of two-person physical support for personal hygiene and transfers. The care plan identified the resident requires assistance with all ADL and mobility. Resident uses the following assistive devices: wheelchair. Interventions included for current function status: to provide total assist of 1 person with daily bathing/grooming/mouth care, to transfer the resident with the assistance of two people via Hoyer lift and to encourage out of bed every day for 2 hours on the 7:00 A.M. to 3:00 P.M. shift. Interview with Person #1 on 9/27/21 at 1:52 P.M. identified the facility staff never get Resident #1 out of bed. Person #1 identified he/she has brought her/his concerns to facility staff during care planning meeting discussions. Person #1 further indicated that due to staff turn-over, many things he/she has discussed with the facility has been falling through the cracks. Person #1 identified there is a camera in Resident #1's room, which is how he/she identified Resident #1 is always observed to be in bed instead out of bed. Person #1 also identified Resident #1 does not receive weekly showers secondary to being in bed. Review of the Nurse Aide (NA) Care Card on 9/28/21 at 8:30 A.M. identified for transfers Resident #1 required the assistance of people 2 via Hoyer lift and directed the resident to be out of bed to Geri-chair for 2 hours/day for lunch. The NA care card identified Resident #1 prefers showers, scheduled on Thursdays during the 3:00 P.M. to 11:00 P.M. shift. Observations on 9/27, 9/28, 9/29, 9/30 and 10/1/21 during the 7:00 A.M. to 3:00 P.M. shift identified Resident #1 remained in bed without the benefit of getting up to a wheelchair. Resident #1 was given a shower on 9/29/21 and was then placed immediately back into bed without the benefit of being in a chair. Interview with NA #1 on 9/29/21 at 12:25 P.M. identified Resident #1 is a difficult transfer as he/she tends to move aggressively once in the Hoyer. NA #1 indicated it takes 2-3 people to transfer resident, but at times the transfer can be unsafe with 2 staff present. NA #1 identified most times s/he is unable to get Resident #1 out of bed due to staffing. NA #1 identified many times s/he can be the only staff working the whole unit and indicated there's no other staff to assist with transfer. NA #1 identified Resident #1 is unable to vocalize refusal, but actions such as screaming/yelling/thrashing would be conceived as refusal. NA #1 identified behaviors such as these should be reported to the RN and charted as refusals in the electronical medical records. Interview with NA #2 on 10/1/21 at 10:20 A.M. identified Resident #1 mainly stays in bed and was unable to provide an explanation why the resident stays in bed. NA #2 identified nurse aides should follow the resident's care card and care plans for resident's preferences. NA #2 was unable to identify what was Resident #1's documented preferences or care plans/care card. NA #2 identified she did not get Resident #1 out of bed yesterday on 9/30/21 during the 7:00 AM to 3:00 PM shift due to shortage of staff which affected Resident #1 from getting out of bed timely. NA #2 identified if a resident refuse to get out of bed, they should report the refusal to the RN and documented in the electronic medical records. Interview with RN #1 on 10/1/21 at 10:30 A.M. identified nurse aides should follow the resident's care card and care plan for resident specific preferences and direction of care. If a resident refuses care, the nurse aides will report to the RN and the RN is responsible for documenting the refusal in the electronic medical records. Interview with DNS on 10/1/21 at 10:35 A.M. identified nurse aides are expected to follow resident's care plan and care cards. If a resident refuse, staff should attempt to encourage the resident but if refusal continues, then report to the RN and document refusal. A review of medical record Behavioral Monitoring on 10/1/21 at 11:15 A.M. identified for all nursing shifts in the month of September 2021 0 of 90 opportunities that Resident #1 had refused to get out of bed. A review of the medical record for Transfers Monitoring on 10/1/21 at 11:25 A.M. identified documentation related to transfer: how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Resident #1 was identified for the month of September 2021, as activity did not occur for 81/90 opportunities. A review of the nursing progress notes dated 10/1/21 at 11:00 A.M. identified 2 documented refusal of care from the time period between 6/01/21 through 10/1/21 by Resident #1. Medical record review of the Showers Monitoring on 10/1/21 at 11:35 A.M. identified in the month of September 2021, Resident #1 was given a shower on 2 documented dates on 9/8/21 and 9/29/21 out of 4 weeks. Review of the AM Care/ADL's Policy identified nursing staff will assist A.M. care for each resident daily as needed. Residents will be encouraged to participate as much as possible. The resident's individual preferences and choices will be honored and included in their morning routine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the clinical record, facility policy and interviews for one resident residents (Resident #11) reviewed for nutrition, the facility failed to assess the resident's nutritional status and failed to obtain a diet order from the physician upon admission and readmission from an acute care facility. The findings include: 1 a. Resident #11 was admitted [DATE] with diagnoses that included fracture of shaft of humerus, left arm, status post closed reduction. A Nutritional assessment dated [DATE] noted Resident #11 was admitted on [DATE] and placed on a regular diet, regular consistency with thin liquids. The nutritional care plan dated 7/16/21 and completed by the Registered Dietician (RD #1), identified Resident #11 required set assistance with meals. Interventions included: the provision of diet as ordered, to provide set-up assistance as needed and to encourage food/fluid intake. The admission MDS assessment dated [DATE], identified Resident # 11 was severely cognitively impaired, independent with eating and required supervised physical assist with personal care. The nursing progress note dated 7/29/21 noted while attending an outside specialty appointment, the facility was notified that Resident #11 had a new dislocation in the left shoulder and that the resident would be transferred for admission to an acute care facility from the scheduled appointment. The nursing progress note dated 8/2/21 noted Resident #11 was readmitted back to the facility following closed reduction of a left shoulder dislocation and showed no signs of dehydration. Review of Discharge summary dated [DATE] did not include a documented diet recommendation for Resident #11. A review of the clinical record between 7/15/21 and 8/2/21 did not identify a documented physician diet order. An Interview and review of medical record with the DNS on 9/30/21 at 10:30 A.M. identified there was no physician diet order in place for the 7/15/21 and 8/2/21 admission. interview with the DNS on 9/30/21 at 10:30 A.M. identified it would have been her expectation that the admitting nurse review discharge summary for the diet recommendation and if not present, to contact the discharging hospital to verify a diet order and then obtain a physician order. Subsequent to inquiry, a current physician's diet order obtained on 9/30/21. b. Further interview with the DNS on 9/30/21 at 10:30 A.M. identified there was no documented nutritional assessment completed following the 8/2/21 readmission. The DNS indicated she would have expected the nutritional assessments be completed according to facility policy. Interview with DNS# 2 on 9/30/21 at 12:27 P.M. identified all orders come from the discharge summary upon arrival to the facility. The admitting nurse would contact the physician to verify the physician's orders and then place in the computer. Additionally, DNS #2 identified RN #4 indicated that she completed the diet slip for Resident #11 but likely provided the diet slip to the kitchen after noticing the kitchen did not receive one without first verifying the order with the physician. Interview with RD #1 on 10/1/21 at 10:00 A.M. indicated that she was in the facility weekly on Fridays to complete nutritional assessments for newly admitted and readmitted residents. RD #1 indicated that she was not aware that Resident #11 returned to the facility on 8/2/21 as she referred to a clinical dashboard in computer program as the only notification of any new admissions and readmissions. RD #1 further indicated Resident #11 was not listed as a new admission and therefore she was not aware of his/her readmission, so the assessments were not completed. RD #1 also indicated Resident #11 was previously placed on a regular diet prior to discharge and that diet orders would have to be discussed with nursing staff. A subsequent interview and facility documentation review with the DNS #1 on 10/1/21 at 10:23 A.M. indicated in addition to computerized notifications, weekly Risk Meetings were held Fridays to discuss in part, new admissions. The DNS #1 also indicated a meeting was held on 8/6/21 where Resident #11 was discussed, and RD #1 was present. Interview with the Registered Dietician on 10/1/21 at 10:41 A.M. indicated she did not recall the meeting. Subsequent to inquiry, a Nutritional Assessment was completed on 9/30/21. Review of Facility policy for admission of a Resident dated November 2016 directed that for any discrepancies in the W10 (Intra-Agency Discharge Summary) paperwork, call the hospital to ascertain exactly what the resident was receiving. Call attending physician or Medical Director for verification of the medications and any other orders written on the W-10. Transcribe the verified orders on to the physician's order sheet. Although a policy for Nutritional Assessments was requested, none was complete

Based on review of the clinical record, review of facility documentation, review of facility policy and interviews reviewed for infection control, the facility failed to test unvaccinated staff in accordance with Centers for Disease Control and Prevention (CDC) recommendations. The findings include: Review of facility documentation of Staff Vaccination Roster on 9/30/21 at 11:30 A.M. identified 6 staff members with an unvaccinated status related to medical or religious exemptions. The 6 staff members identified are: NA #2, NA #3, NA #4, NA #5, TRD and COTA #1. Interview with DNS and RN #2 on 9/30/21 at 11:35 A.M. identified that the facility was performing testing twice a week on unvaccinated staff. In accordance with Centers for Disease Control and Prevention (CDC) Guidelines for Long Term Care Testing identified as of September 10, 2021 recommended an expanded screen testing of asymptomatic Healthcare Personnel (HCP) should be as follows: In nursing homes, unvaccinated HCP should continue to expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a viral test twice a week. Review of the CDC COVID-19 Integrated County View on 09/30/21 identified the level of community transmission in Hartford County for the month of September 2021 was between high to substantial. Review of facility documentation of the weekly staff testing on 9/30/21 at 12:30 P.M. identified the following dates for staff testing: a. Week 1 identified as 8/29/21 to 9/4/21. b. Week 2 identified as 9/5/21 to 9/11/21. c. Week 3 identified as 9/12/21 to 9/18/21. d. Week 4 identified as 9/19/21 to 9/25/21. Review of the facility documentation of the weekly staff testing on 9/30/21 at 12:45 P.M. identified the following staff to be non-compliant with weekly testing: a. NA #3 failed to test twice in Week 1 and Week 4. b. NA #4 failed to test twice in Week 1, Week 2 and Week 4. c. NA #2 failed to test twice in Week 2 d. TRD failed to test twice in Week 1 e. COTA #1 failed to test twice in Week 4. Interview with DNS on 10/1/21 at 2:00 P.M. identified she was unable to provide documentation identifying NA #2, NA # 3, NA # 4, TRD and COTA conducted twice a week testing per CDC Guidelines. The DNS verbalized she has been doing Infection Control for many years but couldn't believe she missed this process. -

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, facility policy, and interviews for one of three residents (Resident #4) reviewed for accidents, the facility failed to follow the resident's plan of care resulting in a fall and /or to prevent a potential accident. The findings include: Resident #4 was admitted to the facility on [DATE] with diagnosis that include difficulty walking. The quarterly MDS assessment dated [DATE] identified Resident #4 had no cognitive impairment, required extensive assistance of 2 or more staff for physical assistance with transfer, toilet use and personal hygiene, had 2 or more falls since admission and/or last assessment with no injury. The quarterly assessment also noted the resident had 1 fall since admission and/or last assessment with injury (except major). The care plan dated 3/22/19 identified Resident #4 was at risk for falls secondary many falls with/without injury in the past, multiple risk factors such as: impaired balance, decreased strength and impaired gait due to bilateral foot and hammer toe deformities, sometimes experienced lower extremity and foot numbness due to peripheral neuropathy. Additionally, the care plan noted at risk for falls due to a history of syncope and seizures and non-compliant with waiting for assistance with mobility. Interventions directed a 2 person assist with sit-to stand mechanical lift for all transfers to ensure safe transfers and indicated the resident was non-ambulatory. A monthly physician's order dated 4/28/19 directed assistance of 2 staff for transfers, standing mechanical lift if resident became fatigued. A Reportable Event (RE) form dated 5/20/19 at 8:20 P.M. identified Resident #4 was being assisted by a NA # 2 to transfer from the wheelchair to the toilet. Resident #4 started to fall and the NA#2 eased the resident to the floor. The facility investigation of the incident on 5/20/19 identified Resident #4 was transferred from wheelchair to the toilet by NA #2. Resident #4's care plan at the time of the incident on 5/20/19 directed the assistance of two staff members to transfer Resident # 4 via mechanical sit-to-stand lift. Resident #4 was attempting to transfer from the wheelchair to the toilet with assistance of 1 staff member, the resident was non-ambulatory and could not bear weight and indicated the resident was transferred without the benefit of two staff members in accordance to the plan of care. Education to staff was provided to transfer Resident #4 with a sit-to-stand mechanical lift at all times. The late entry nurse's note dated 5/20/19 at 9:34 P.M. identified Resident #4 had a witnessed fall. NA #2 was attempting to transfer resident from the wheelchair to the toilet. Resident #4 could not bear weight and started to fall. The NA #2 eased Resident #4 to the floor. The resident did not hit his/her head. Resident #4 was lying on bathroom floor on his/her back. After a full assessment with no concerns noted the resident was transferred from the floor to her/his bed by three staff members via Hoyer lift. No complaints of pain or discomfort was noted at the time of the assessment. No apparent signs of injury noted and the resident's skin was intact. Additionally, the late entry nurse's note indicated the resident's family member was concerned that NA #2 attempted to transfer the resident by her/ himself despite Resident #4's current transfer status of assistance of 2 staff with sit-to-stand mechanical lift. The facility staff notified the resident's family member that NA #2 failed to follow Resident # 4's plan of care. NA # 2 was educated on following the resident's plan of care by using 2 staff members to transfer the resident via mechanical lift. Review of facility documentation identified NA #2 was educated on 5/20/19 regarding following the resident's care card and receiving full report. NA #2 was instructed to ask questions regarding resident's diet, transfer status and diagnosis. An interview with NA #2 on 6/12/19 at 2:10 P.M. identified she/he (NA #2) did not check Resident #4's care card and indicated she/he assumed Resident #4 required assistance of 1 staff with transfer. The resident could ambulate. NA #2 indicated she/he attempted to transfer Resident #4 from the wheelchair to the toilet by him/herself and Resident #4 was unable to bear weight, the resident started to fall so she/he (NA #2) lowered Resident #4 to the floor. NA #2 also indicated she/he was unaware of Resident #4 requiring assistance of 2 staff with sit-to-stand mechanical lift. NA #2 indicated the nursing supervisor in-serviced her/him on the need to utilize assistance of 2 staff with a sit-to-stand mechanical lift when transferring Resident # 4. NA #2 was also instructed to review Resident #4's care card before providing care. Review of facility falls: minimizing risk of injury policy identified that an individualized care plan will be developed and updated as needed to identify interventions to prevent falls and minimize injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility policy and interviews for one of three residents (Resident # 7) reviewed for psychotropic medications, the facility failed to properly monitor targeted behaviors and/or follow physician orders for orthostatic Blood Pressures (BP) in accordance to the plan of care and/or facility policy. The findings include: Resident #7's diagnoses included dementia with behavioral disorder, anxiety disorder and insomnia. The quarterly MDS assessment dated [DATE] identified the resident was severely cognitively impaired, had memory problems and required extensive assistance with personal hygiene. Additionally, the quarterly assessment indicated the resident utilized 7 anti-depressant medication within the last 7 days of the assessment. The Resident Care Plan (RCP) dated 11/12/18 identified resident displayed inappropriate behavior that included resistive to redirection, noncompliant and verbally aggressive to staff. Interventions included flexibility in routine to accommodate resident's mood, directed staff to document resistance to care. The RCP dated /1/4/19 identified Resident #7 used psychotropic medications related to anxiety. Intervention included to have the Medical Doctor (MD) evaluate effectiveness and side effects and vital signs per policy. The RCP dated 1/19/19 further identified Resident #7 is forgetful and confused due to dementia and to allow time to respond when speaking to her/him. The quarterly Minimum Data Set ( MDS) assessment dated [DATE] identified Resident #7 had severely impaired cognition, the resident required extensive assistance with 2 staff for personal hygiene, dressing and locomotion on unit. A physician's order dated 3/20/19 directed Seroquel (Antipsychotic) 25 Milligrams (MG) at bedtime. The nurse's notes dated 5/20/19 at 7:18 A.M. identified Resident #7 had visual hallucinations that included seeing dog paw shadows under the bathroom door, 2 holes in the bedroom wall with cameras and a man behind the wall watching him/ her through the cameras. The nurse's note further directed staff to place Resident # 7's name in book to be seen by APRN. A physician's order dated 5/20/19 directed to discontinue Seroquel 25 MG at bedtime, to start 50MG at bedtime and to add Seroquel 25 MG every day for non-directable hallucinations and delusions for 14 days. The physician's orders further directed to monitor orthostatic blood pressures every week times 4 weeks then monthly. The physician's order dated 5/21/19 directed to provide Seroquel 25MG daily when needed for non-directable hallucinations and delusions. The physician's orders dated 5/29/19 directed to discontinue Seroquel 50 MG at bedtime and start 37.5MG at bedtime. The Target Behavior monitoring sheets dated 5/20/19 through 6/12/19 failed to identify a behavior of non-directable hallucinations and delusions as a targeted behavior for tracking. The Target Behavior monitoring sheets dated 6/1/19 through 6/12/19 identified sleep disturbance was added to the behaviors but the sheet failed to specifically identify the exact behavior demonstrated by Resident #7. A review of Resident #7's weight and vitals summary identified Resident #7's orthostatic BPs were completed for 3 of the 4 ordered weeks (5/21/19, 6/4/19 and 6/11/19) lacking orthostatic BP's for week 3 in accordance to the physician's order. The Medication Administration Record (MAR) dated 5/20/19 through 6/12/19 identified Resident # 7 received all scheduled doses of medication. Interview and review of the medical record with DNS on 6/12/19 at 10:20 A.M. identified staff failed to follow the physician's ordered for monitoring parameters and indicated the behavior monitoring sheets lacked the specific behaviors for non-directable hallucinations and delusions. Facility policy for Psychopharmacological Medication Use notes for each resident receiving psychopharmacological medication, facility staff should monitor behavioral triggers, episodes and symptoms documenting the number and/or intensity of symptoms and the resident's response

Based on observations, review of facility documentation and interviews, the facility failed to ensure that food was contained and /or stored to prevent flies in the hallway and/or residents room in accordance with professional standard for food service. The findings include: On 6/12/19 at 10:38 A.M. during an observation of a resident sitting in the hallway identified a fly observed buzzing around the hallway, landing on the resident's hand, on the nursing station countertop, inside of an open container of apple sauce and open container of chocolate pudding stored on top of a medication cart. LPN #1 was observed coming out of resident's room, walking in the hallway by the medication cart and sitting in the nursing station. Interview with LPN #1 on 6/12/19 at 10:50 A.M. identified she/he did not notice the fly sitting on the open container of chocolate pudding. LPN #1 further indicated she/he usually close food containers tightly but was unsure why she/he left them open. LPN #1 verbalized that she/he was planning on using the apple sauce and chocolate pudding during medications administration to residents this afternoon. Subsequent to surveyor inquiry, LPN #1 discarded the apple sauce and chocolate pudding. During an interview, on 6/13/19 at 10:20 A.M RN #2 indicated unattended food should had not been left open on the medication cart and all food items must be stored in air tight containers.